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Yang Y, Zhang F, Shi H, Zhu Z, Zhou Y, Zhou Y. Differential diagnostic value of simultaneous detection of CD69 and HLA-DR on host T and NK cells in QFT-TB assay for identifying active tuberculosis. Tuberculosis (Edinb) 2024; 148:102537. [PMID: 38954896 DOI: 10.1016/j.tube.2024.102537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 06/18/2024] [Accepted: 06/27/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Interferon-gamma release assay (IGRA) for tuberculosis (TB) remains limited in its ability to discriminate between active TB (ATB) and latent TB infection (LTBI). Activation markers on host T and NK cells are currently considered to be promising markers in the diagnosis of ATB. METHODS This prospective observational study enrolled 213 participants and the participants were divided into ATB, LTBI, other lung-related diseases (ORD), and health control (HC) groups. CD69 and HLA-DR on T and NK cells were detected in QFT-TB assay, and a composite scoring system (TB-Flow) was created for the diagnosis of ATB. RESULTS The expression of activation markers (CD69 and HLA-DR) were significantly increased in ATB. HLA-DR on NK cells, CD69 on T cells, and QFT-TB in the differential diagnosis of ATB and HC were all of good diagnostic value (AUC>0.90). In addition, the TB-Flow greatly improved the efficiency of differential diagnosis between ATB and LTBI (AUC=0.90, 95%CI: 0.84-0.96), with sensitivity and specificity of 79.17 % (95%CI: 64.60%-89.04 %) and 88.68 % (95%CI: 76.28%-95.31 %). CONCLUSIONS CD69 and HLA-DR on host T and NK cells are promising markers in distinguishing different TB infection status. Our blood-based TB-Flow scoring system can distinguish ATB from LTBI with good diagnostic efficacy.
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Affiliation(s)
- Yiqi Yang
- Laboratory Medicine Center, Department of Clinical Laboratory, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang 310014, China; School of Medical Technology and Information Engineering, Zhejiang Chinese Medical University, Hangzhou 310053, China.
| | - Fujie Zhang
- Qian Xi Nan Hospital of Traditional Chinese Medicine, Qian Xi Nan Buyei, and Miao Autonomous Prefecture 562499, China.
| | - Hanlu Shi
- Clinical Research Center, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 360000, China.
| | - Zhongliang Zhu
- Laboratory Medicine Center, Department of Clinical Laboratory, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang 310014, China.
| | - Yu Zhou
- Laboratory Medicine Center, Department of Clinical Laboratory, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang 310014, China.
| | - Yonglie Zhou
- Laboratory Medicine Center, Department of Clinical Laboratory, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang 310014, China.
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Mo S, Shi C, Cai Y, Xu M, Xu H, Xu Y, Zhang K, Zhang Y, Liu J, Che S, Liu X, Xing C, Long X, Chen X, Liu E. Single-cell transcriptome reveals highly complement activated microglia cells in association with pediatric tuberculous meningitis. Front Immunol 2024; 15:1387808. [PMID: 38745656 PMCID: PMC11091396 DOI: 10.3389/fimmu.2024.1387808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 04/16/2024] [Indexed: 05/16/2024] Open
Abstract
Background Tuberculous meningitis (TBM) is a devastating form of tuberculosis (TB) causing high mortality and disability. TBM arises due to immune dysregulation, but the underlying immune mechanisms are unclear. Methods We performed single-cell RNA sequencing on peripheral blood mononuclear cells (PBMCs) and cerebrospinal fluid (CSF) cells isolated from children (n=6) with TBM using 10 xGenomics platform. We used unsupervised clustering of cells and cluster visualization based on the gene expression profiles, and validated the protein and cytokines by ELISA analysis. Results We revealed for the first time 33 monocyte populations across the CSF cells and PBMCs of children with TBM. Within these populations, we saw that CD4_C04 cells with Th17 and Th1 phenotypes and Macro_C01 cells with a microglia phenotype, were enriched in the CSF. Lineage tracking analysis of monocyte populations revealed myeloid cell populations, as well as subsets of CD4 and CD8 T-cell populations with distinct effector functions. Importantly, we discovered that complement-activated microglial Macro_C01 cells are associated with a neuroinflammatory response that leads to persistent meningitis. Consistently, we saw an increase in complement protein (C1Q), inflammatory markers (CRP) and inflammatory factor (TNF-α and IL-6) in CSF cells but not blood. Finally, we inferred that Macro_C01 cells recruit CD4_C04 cells through CXCL16/CXCR6. Discussion We proposed that the microglial Macro_C01 subset activates complement and interacts with the CD4_C04 cell subset to amplify inflammatory signals, which could potentially contribute to augment inflammatory signals, resulting in hyperinflammation and an immune response elicited by Mtb-infected tissues.
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Affiliation(s)
- Siwei Mo
- Department of Respiratory Medicine, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children’s Hospital of Chongqing Medical University, Chongqing Key Laboratory of Pediatrics, Chongqing, China
- Guangdong Provincial Key Laboratory of Regional Immunity and Diseases, Department of Pathogen Biology, School of Medicine, Shenzhen University, Shenzhen, China
| | - Chenyan Shi
- Guangdong Provincial Key Laboratory of Regional Immunity and Diseases, Department of Pathogen Biology, School of Medicine, Shenzhen University, Shenzhen, China
- School of Public Health, Shenzhen University Medical School, Shenzhen University, Shenzhen, Guangdong, China
| | - Yi Cai
- Guangdong Provincial Key Laboratory of Regional Immunity and Diseases, Department of Pathogen Biology, School of Medicine, Shenzhen University, Shenzhen, China
| | - Maozhu Xu
- Maternal and Child Care Health Hospital of Zunyi City, Zunyi, Guizhou, China
| | - Hongmei Xu
- Department of Infectious Diseases, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Yuzhong Xu
- Department of Clinical Laboratory, Shenzhen Baoan Hospital, The Second Affiliated Hospital of Shenzhen University, Shenzhen University, Shenzhen, China
| | - Kehong Zhang
- Department of Clinical Laboratory, Shenzhen Baoan Hospital, The Second Affiliated Hospital of Shenzhen University, Shenzhen University, Shenzhen, China
| | - Yue Zhang
- Guangdong Provincial Key Laboratory of Regional Immunity and Diseases, Department of Pathogen Biology, School of Medicine, Shenzhen University, Shenzhen, China
| | - Jiao Liu
- Pediatric Research Institute, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Siyi Che
- Department of Radiology, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Xiangyu Liu
- Department of Respiratory Medicine, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children’s Hospital of Chongqing Medical University, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Chaonan Xing
- Guangdong Provincial Key Laboratory of Regional Immunity and Diseases, Department of Pathogen Biology, School of Medicine, Shenzhen University, Shenzhen, China
| | - Xiaoru Long
- Department of Respiratory Medicine, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children’s Hospital of Chongqing Medical University, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Xinchun Chen
- Guangdong Provincial Key Laboratory of Regional Immunity and Diseases, Department of Pathogen Biology, School of Medicine, Shenzhen University, Shenzhen, China
| | - Enmei Liu
- Department of Respiratory Medicine, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children’s Hospital of Chongqing Medical University, Chongqing Key Laboratory of Pediatrics, Chongqing, China
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Mi J, Liu Y, Xue Y, Sun W, Liang Y, Liang J, An H, Wu X. The changes and its significance of peripheral blood NK cells in patients with tuberculous meningitis. Front Microbiol 2024; 15:1344162. [PMID: 38486698 PMCID: PMC10937341 DOI: 10.3389/fmicb.2024.1344162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 02/01/2024] [Indexed: 03/17/2024] Open
Abstract
Objective Tuberculous meningitis (TBM) is the most severe form of tuberculosis (TB). The purpose of this study was to explore the relationship between the number of natural killer (NK) cells and adaptive immune status, and disease severity in TBM patients. Methods We conducted a retrospective study on 244 TB patients and 146 healthy control subjects in the 8th Medical Center of the PLA General Hospital from March 2018 and August 2023. Results The absolute count of NK cells in the peripheral blood of TBM patients was significantly lower than that in normal controls (NC), latent tuberculosis infection (LTBI), and non-severe TB (NSTB) patients (p < 0.05). The proportion of TBM patients (48.7%) with a lower absolute count of NK cells than the normal reference value was significantly higher than that in NC (5.2%) and LTBI groups (4.0%) (p < 0.05), and slightly higher than that in NSTB group (36.0%) (p > 0.05). The absolute counts of lymphocyte subsets in TBM combined with other active TB group, etiology (+) group, IGRA (-) group, and antibody (+) group were lower than that in simple TBM group, etiology (-) group, IGRA (+) group, and antibody (-) group, respectively. The CD3+ T, NK, and B cells in BMRC-stage III TBM patients were significantly lower than those in stage I and stage II patients (p < 0.05). The counts of CD3+ T, CD4+ T, and B cells in the etiology (+) group were significantly lower than those in the etiology (-) group (p < 0.05). Conclusion The absolute counts of lymphocyte subsets in the peripheral blood of TBM patients were significantly decreased, especially in NK cells. The reduction of these immune cells was closely related to the disease severity and had a certain correlation with cellular and humoral immune responses. This study helps to better understand the immune mechanism of TBM and provides reliable indicators for evaluating the immune status of TBM patients in clinical practice.
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Affiliation(s)
- Jie Mi
- Beijing Key Laboratory of New Techniques of Tuberculosis Diagnosis and Treatment, Institute of Tuberculosis Research, Senior Department of Tuberculosis, The 8th Medical Center of PLA General Hospital, Beijing, China
| | - Yinping Liu
- Beijing Key Laboratory of New Techniques of Tuberculosis Diagnosis and Treatment, Institute of Tuberculosis Research, Senior Department of Tuberculosis, The 8th Medical Center of PLA General Hospital, Beijing, China
| | - Yong Xue
- Beijing Key Laboratory of New Techniques of Tuberculosis Diagnosis and Treatment, Institute of Tuberculosis Research, Senior Department of Tuberculosis, The 8th Medical Center of PLA General Hospital, Beijing, China
| | - Wenna Sun
- Beijing Key Laboratory of New Techniques of Tuberculosis Diagnosis and Treatment, Institute of Tuberculosis Research, Senior Department of Tuberculosis, The 8th Medical Center of PLA General Hospital, Beijing, China
| | - Yan Liang
- Beijing Key Laboratory of New Techniques of Tuberculosis Diagnosis and Treatment, Institute of Tuberculosis Research, Senior Department of Tuberculosis, The 8th Medical Center of PLA General Hospital, Beijing, China
| | - Jianqin Liang
- Department of Tuberculosis, Senior Department of Tuberculosis, The 8th Medical Center of PLA General Hospital, Beijing, China
| | - Huiru An
- Department of Tuberculosis, Senior Department of Tuberculosis, The 8th Medical Center of PLA General Hospital, Beijing, China
| | - Xueqiong Wu
- Beijing Key Laboratory of New Techniques of Tuberculosis Diagnosis and Treatment, Institute of Tuberculosis Research, Senior Department of Tuberculosis, The 8th Medical Center of PLA General Hospital, Beijing, China
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Ma Q, Chen J, Kong X, Zeng Y, Chen Z, Liu H, Liu L, Lu S, Wang X. Interactions between CNS and immune cells in tuberculous meningitis. Front Immunol 2024; 15:1326859. [PMID: 38361935 PMCID: PMC10867975 DOI: 10.3389/fimmu.2024.1326859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 01/10/2024] [Indexed: 02/17/2024] Open
Abstract
The central nervous system (CNS) harbors its own special immune system composed of microglia in the parenchyma, CNS-associated macrophages (CAMs), dendritic cells, monocytes, and the barrier systems within the brain. Recently, advances in the immune cells in the CNS provided new insights to understand the development of tuberculous meningitis (TBM), which is the predominant form of Mycobacterium tuberculosis (M.tb) infection in the CNS and accompanied with high mortality and disability. The development of the CNS requires the protection of immune cells, including macrophages and microglia, during embryogenesis to ensure the accurate development of the CNS and immune response following pathogenic invasion. In this review, we summarize the current understanding on the CNS immune cells during the initiation and development of the TBM. We also explore the interactions of immune cells with the CNS in TBM. In the future, the combination of modern techniques should be applied to explore the role of immune cells of CNS in TBM.
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Affiliation(s)
| | | | | | | | | | | | | | - Shuihua Lu
- National Clinical Research Center for Infectious Disease, Shenzhen Third People's Hospital, Shenzhen, Guangdong, China
| | - Xiaomin Wang
- National Clinical Research Center for Infectious Disease, Shenzhen Third People's Hospital, Shenzhen, Guangdong, China
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Barnacle JR, Davis AG, Wilkinson RJ. Recent advances in understanding the human host immune response in tuberculous meningitis. Front Immunol 2024; 14:1326651. [PMID: 38264653 PMCID: PMC10803428 DOI: 10.3389/fimmu.2023.1326651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 12/18/2023] [Indexed: 01/25/2024] Open
Abstract
Tuberculous meningitis (TBM), the most severe form of tuberculosis, causes death in approximately 25% cases despite antibiotic therapy, and half of survivors are left with neurological disability. Mortality and morbidity are contributed to by a dysregulated immune response, and adjunctive host-directed therapies are required to modulate this response and improve outcomes. Developing such therapies relies on improved understanding of the host immune response to TBM. The historical challenges in TBM research of limited in vivo and in vitro models have been partially overcome by recent developments in proteomics, transcriptomics, and metabolomics, and the use of these technologies in nested substudies of large clinical trials. We review the current understanding of the human immune response in TBM. We begin with M. tuberculosis entry into the central nervous system (CNS), microglial infection and blood-brain and other CNS barrier dysfunction. We then outline the innate response, including the early cytokine response, role of canonical and non-canonical inflammasomes, eicosanoids and specialised pro-resolving mediators. Next, we review the adaptive response including T cells, microRNAs and B cells, followed by the role of the glutamate-GABA neurotransmitter cycle and the tryptophan pathway. We discuss host genetic immune factors, differences between adults and children, paradoxical reaction, and the impact of HIV-1 co-infection including immune reconstitution inflammatory syndrome. Promising immunomodulatory therapies, research gaps, ongoing challenges and future paths are discussed.
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Affiliation(s)
- James R. Barnacle
- The Francis Crick Institute, London, United Kingdom
- Department of Infectious Disease, Imperial College, London, United Kingdom
- Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
| | - Angharad G. Davis
- The Francis Crick Institute, London, United Kingdom
- Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
| | - Robert J. Wilkinson
- The Francis Crick Institute, London, United Kingdom
- Department of Infectious Disease, Imperial College, London, United Kingdom
- Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
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6
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Zhang X, Zhao Z, Wu Q, Wang L, Li L, Wang M, Ren Y, Pan L, Tang H, Li F. Single-cell analysis reveals changes in BCG vaccine-injected mice modeling tuberculous meningitis brain infection. Cell Rep 2023; 42:112177. [PMID: 36862557 DOI: 10.1016/j.celrep.2023.112177] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 09/28/2022] [Accepted: 02/13/2023] [Indexed: 03/03/2023] Open
Abstract
Tuberculous meningitis (TBM) is the most severe and deadly manifestation of tuberculosis. Neurological complications are observed in up to 50% of patients affected. Here, attenuated Mycobacterium bovis are injected into the cerebellum of mice, and histopathological images and cultured colonies confirm successful brain infection. Then, whole-brain tissue is dissected for 10X Genomics single-cell sequencing, and we acquire 15 cell types. Transcriptional changes of inflammation processes are found in multiple cell types. Specifically, Stat1 and IRF1 are shown to mediate inflammation in macrophages and microglia. For neurons, decreased oxidative phosphorylation activity in neurons is observed, which corresponds to TBM clinical symptoms of neurodegeneration. Finally, ependymal cells present prominent transcriptional changes, and decreased FERM domain containing 4A (Frmd4a) may contribute to TBM clinical symptoms of hydrocephalus and neurodegeneration. This study shows a single-cell transcriptome of M. bovis infection in mice and improves the understanding of brain infection and neurological complications in TBM.
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Affiliation(s)
- Xiaolin Zhang
- Department of Respiratory Disease and Critical Care Medicine, Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China
| | - Zhangyan Zhao
- Department of Respiratory Disease and Critical Care Medicine, Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China
| | - Qingguo Wu
- Department of Respiratory Disease and Critical Care Medicine, Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China
| | - Lei Wang
- Department of Respiratory Disease and Critical Care Medicine, Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China
| | - Liqun Li
- Department of Respiratory Disease and Critical Care Medicine, Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China
| | - Mei Wang
- Department of Respiratory Disease and Critical Care Medicine, Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China
| | - Yang Ren
- Department of Respiratory Disease and Critical Care Medicine, Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China
| | - Lei Pan
- Department of Respiratory Disease and Critical Care Medicine, Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China
| | - Haicheng Tang
- Department of Respiratory Disease and Critical Care Medicine, Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China.
| | - Feng Li
- Department of Respiratory Disease and Critical Care Medicine, Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China; Shanghai Institute of Infectious Disease and Biosecurity, Fudan University, Shanghai 200032, China.
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Pinzon RT, Veronica V. Hydrocephalus Caused by Tuberculous Meningitis in an Immunocompetent Young Adult: A Case Report. Int Med Case Rep J 2023; 16:187-192. [PMID: 36968269 PMCID: PMC10038010 DOI: 10.2147/imcrj.s389204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 01/20/2023] [Indexed: 03/22/2023] Open
Abstract
Background Despite improved medical management, meningeal tuberculosis mortality and other outcomes have changed slightly over time due to a delay in diagnosis and treatment. This study reports a rare case of tuberculous meningitis in an immunocompetent host, calling into question the commonly held belief that tuberculous meningitis is a disease of immunocompromised individuals. Case Presentation A 26-year-old male with no significant past medical history, tuberculosis, or indications of immunological compromise, was admitted to our hospital with a fever and altered mental status. He was drowsy, febrile (temperature of 38°C), had a heart rate of 110 beats per minute, and showed mild neck stiffness but no meningeal sign. A lumbar puncture on the third day of admission suggested tuberculous meningitis. He was treated for tuberculosis meningitis, and his condition slightly improved. However, the patient's condition suddenly worsened, and a repeat contrast computed tomography (CT) of the brain showed the development of ventriculomegaly and basilar enhancement. Insertion of an emergency ventriculoperitoneal shunt was performed; however, the patient died ten days after hospital admission. Conclusion We report a fatal case of tuberculous meningitis in an immunocompetent patient. Healthcare practitioners must be trained to identify and diagnose tuberculous meningitis promptly. Early treatment of tuberculous meningitis based on clinical diagnosis and symptoms improves clinical outcomes.
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Affiliation(s)
- Rizaldy Taslim Pinzon
- Faculty of Medicine, Duta Wacana Christian University, Yogyakarta, Indonesia
- Department of Neurology, Bethesda Hospital, Yogyakarta, Indonesia
- Correspondence: Rizaldy Taslim Pinzon, Duta Wacana Christian University School of Medicine, Doctor Wahidin Sudirohusodo St. 5-25, Yogyakarta, 55224, Indonesia, Email
| | - Vanessa Veronica
- Faculty of Medicine, Duta Wacana Christian University, Yogyakarta, Indonesia
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Tribolet L, Brice AM, Fulford TS, Layton DS, Godfrey DI, Bean AGD, Stewart CR. Identification of a novel role for the immunomodulator ILRUN in the development of several T cell subsets in mice. Immunobiology 2023; 228:152380. [PMID: 37031606 DOI: 10.1016/j.imbio.2023.152380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 03/20/2023] [Accepted: 03/26/2023] [Indexed: 03/31/2023]
Abstract
Inflammation and lipid regulator with UBA-like and NBR1-like domains (ILRUN) is a protein-encoding gene associated with innate immune signaling, lipid metabolism and cancer. In the context of innate immunity, ILRUN inhibits IRF3-mediated transcription of antimicrobial and proinflammatory cytokines by inducing degradation of the transcriptional coactivators CBP and p300. There remains a paucity of information, however, regarding the innate immune roles of ILRUN beyond in vitro analyses. To address this, we utilize a knockout mouse model to investigate the effect of ILRUN on cytokine expression in splenocytes and on the development of immune cell populations in the spleen and thymus. We show elevated production of tumor necrosis factor and interleukin-6 cytokines in ILRUN-deficient splenocytes following stimulation with the innate immune ligands polyinosinic:polycytidylic acid or lipopolysaccharide. Differences were also observed in the populations of several T cell subsets, including regulatory, mucosal-associated invariant and natural killer. These data identify novel functions for ILRUN in the development of certain immune cell populations and support previous in vitro findings that ILRUN negatively regulates the synthesis of pathogen-stimulated cytokines. This establishes the ILRUN knockout mouse model as a valuable resource for further study of the functions of ILRUN in health and disease.
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Affiliation(s)
- Leon Tribolet
- CSIRO Health & Biosecurity, Australian Centre for Disease Preparedness, Geelong 3220, Victoria, Australia
| | - Aaron M Brice
- CSIRO Health & Biosecurity, Australian Centre for Disease Preparedness, Geelong 3220, Victoria, Australia
| | - Thomas S Fulford
- Department of Microbiology and Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne 3000, Victoria, Australia
| | - Daniel S Layton
- CSIRO Health & Biosecurity, Australian Centre for Disease Preparedness, Geelong 3220, Victoria, Australia
| | - Dale I Godfrey
- Department of Microbiology and Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne 3000, Victoria, Australia
| | - Andrew G D Bean
- CSIRO Health & Biosecurity, Australian Centre for Disease Preparedness, Geelong 3220, Victoria, Australia
| | - Cameron R Stewart
- CSIRO Health & Biosecurity, Australian Centre for Disease Preparedness, Geelong 3220, Victoria, Australia.
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Ma C, Lu Y, Zhang Q, Chen H, Zhang Q, Hu H, Song Z, Chen R, Liu D. Comparisons in the changes of clinical characteristics and cerebrospinal fluid cytokine profiles between varicella-zoster virus meningitis/encephalitis and other central nervous system infections. ZHONG NAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF CENTRAL SOUTH UNIVERSITY. MEDICAL SCIENCES 2022; 47:1345-1354. [PMID: 36411685 PMCID: PMC10930359 DOI: 10.11817/j.issn.1672-7347.2022.210725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Indexed: 06/16/2023]
Abstract
OBJECTIVES Varicella-zoster virus (VZV) is one of the most common etiologies of viral meningitis/encephalitis. The early clinical manifestations and cerebrospinal fluid (CSF) changes of VZV meningitis/encephalitis lack specificity, and it is easy to be misdiagnosed as other viral encephalitides or tuberculous meningitis. This study aims to investigate whether the clinical characteristics, CSF analysis findings, and CSF cytokine levels could distinguish VZV meningitis/encephalitis from central nervous system (CNS) herpes simplex virus (HSV) and Mycobacterium tuberculosis (MTB) infections. METHODS The medical records from 157 CNS infections, including 49 HSV (45 HSV-1, 4 HSV-2), 55 VZV, and 53 MTB infections between January 2018 and June 2021 in the Cytology Laboratory, Department of Neurology, Third Xiangya Hospital of Central South University were retrospectively reviewed. The data of 3 groups included demographic characteristics, laboratory results, radiographic findings, and outcomes. The levels of 12 cytokines (IL-1β, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12p70, IL-17, IFN-γ, IFN-α, and TNF-α) in the CSF of 68 patients (13 HSV, 22 VZV, and 33 MTB infection cases) were quantified. Clinical and laboratory data were compared among the 3 groups. RESULTS The most common clinical manifestations in the 3 groups were fever, headache, vomiting, and neck stiffness. The clinical manifestations of HSV and VZV CNS disease were similar, although fever and altered consciousness were less common in the VZV group than those in the HSV and MTB groups (63.6% vs 87.8% vs 96.2%, P<0.001, and 14.5% vs 26.5% vs 47.2%, P=0.004, respectively). Seven patients (7/55, 12.7%) presented cutaneous zoster in the VZV group. CSF leukocyte count was significantly higher in the VZV group (230×106 cells/mL) and MTB groups (276×106 cells/mL) than that in the HSV group (87×106 cells/mL, P=0.002). CSF protein level was significantly higher in the VZV than that in the HSV group (1 034 mg/L vs 694 mg/L, P=0.011) but lower than that in the MTB group (1 744 mg/L, P<0.001). IL-6 (VZV vs HSV vs MTB: 2 855.93 pg/mL vs 2 128.26 pg/mL vs 354.77 pg/mL, P=0.029) and IL-8 (VZV vs HSV vs MTB: 4 001.46 pg/mL vs 1 578.11 pg/mL vs 1 023.25 pg/mL, P=0.046) levels were significantly different among the 3 groups and were elevated in the VZV group.Post hoc analysis revealed that IL-6 and IL-8 were significantly higher in the VZV group than those in the MTB group (P=0.002 and P=0.035, respectively), but not in the HSV group (P>0.05). CONCLUSIONS VZV meningitis/encephalitis presents with CSF hypercellularity and proteinemia, challenging the classical view of CSF profiles in viral encephalitis. CSF IL-6 and IL-8 levels are elevated in patients with VZV meningitis/encephalitis, indicating a more intense inflammatory response in these patients.
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Affiliation(s)
- Caiyu Ma
- Department of Neurology, Third Xiangya Hospital, Central South University, Changsha 410013.
| | - Yuying Lu
- Key Laboratory of Microbial Molecular Biology of Hunan Province, Hunan Provincial Center for Disease Control and Prevention, Changsha 410005, China
| | - Qinghua Zhang
- Department of Neurology, Third Xiangya Hospital, Central South University, Changsha 410013
| | - Han Chen
- Department of Neurology, Third Xiangya Hospital, Central South University, Changsha 410013
| | - Qingxia Zhang
- Department of Neurology, Third Xiangya Hospital, Central South University, Changsha 410013
| | - Hao Hu
- Department of Neurology, Third Xiangya Hospital, Central South University, Changsha 410013
| | - Zhi Song
- Department of Neurology, Third Xiangya Hospital, Central South University, Changsha 410013
| | - Ru Chen
- Department of Neurology, Third Xiangya Hospital, Central South University, Changsha 410013.
| | - Ding Liu
- Department of Neurology, Third Xiangya Hospital, Central South University, Changsha 410013.
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Jiang Y, Xu X, Guo Z, Liu Y, Lin J, Suo L, Jiang Y, Liu B, Lu T. Myelitis: A Common Complication of Tuberculous Meningitis Predicting Poor Outcome. Front Neurol 2022; 13:830029. [PMID: 35370906 PMCID: PMC8965833 DOI: 10.3389/fneur.2022.830029] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/07/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundMyelitis is an important complication in patients with tuberculous meningitis (TBM). However, a paucity of publications exists on the spectrum of neurological and MRI findings of TBM-related myelitis. The risk factors and prognosis of myelitis in patients with TBM are not fully understood. Therefore, this study aims to identify the risk factors, clinicoradiological features, and prognostic impact of myelitis for patients with TBM.MethodsWe conducted a retrospective study in our institution. Patients with TBM who were consecutively admitted during the period of August 2015 to December 2019 were included. We reviewed the demographic characteristics, clinical, laboratory and MRI findings, and clinical outcomes of all of the included patients. The diagnosis of myelitis was identified by a hyperintensity on T2-weighted images that were associated with cord edema, enlargement, and marginal or no enhancement on contrast-enhanced images.ResultsA total of 114 patients were included. Myelitis occurred in 19 (16.7%) patients, five of whom paradoxically developed myelitis. The common clinical signs of myelitis were paraparesis (738.9%), quadriparesis (844.4%), urinary retention or constipation (1,477.8%), and paresthesias in the lower limbs (1,052.6%). In the MRI findings, the hyperintensities on T2-weighted images involved more than 3 spinal cord segments. Myelitis was often combined with other forms of spinal cord injury, including 10 patients (52.6%) with spinal meningeal enhancement, 7 patients (36.8%) with enlargement of the central canal of the spinal cord, 6 patients (31.6%) with tuberculoma, and 4 patients (21.1%) with arachnoiditis and 1 patient (5.3%) with cerebrospinal fluid (CSF) loculations. None of the 5 patients with paradoxical myelitis were complicated with spinal meningeal enhancement and arachnoiditis, while 4 patients were complicated with enlargements of the central canal of the spinal cord. In multivariable analysis, a grade III disease severity on admission [p = 0.003, odds ratio (OR) = 8.131, 95% CI: 2.080–31.779] and high CSF protein (p = 0.033, OR = 1.698, 95% CI: 1.043–2.763) were independent risk factors for myelitis. After the 6 months follow-up, myelitis (p = 0.030, OR = 13.297, 95% CI: 1.283–137.812) and disturbance of consciousness (p = 0.042, OR = 12.625, 95% CI: 1.092–145.903) were independent risk factors for poor outcomes.ConclusionMyelitis was a common complication of TBM and independently predicted a poor outcome. A grade III disease severity and high CSF protein on admission were independent risk factors for myelitis. Paradoxical myelitis was rarely complicated with spinal meningeal enhancements and arachnoiditis, indicating that the immune reaction may play a dominant role.
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Affiliation(s)
- Yuxuan Jiang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiangqin Xu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhuoxin Guo
- Department of Radiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yuxin Liu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jiahao Lin
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Lijun Suo
- Zibo City Key Laboratory of Respiratory Infection and Clinical Microbiology, Department of Pulmonary and Critical Care Medicine, Zibo City Engineering Technology Research Center of Etiology Molecular Diagnosis, Zibo Municipal Hospital, Zibo, China
| | - Ying Jiang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Bo Liu
- Zibo City Key Laboratory of Respiratory Infection and Clinical Microbiology, Department of Pulmonary and Critical Care Medicine, Zibo City Engineering Technology Research Center of Etiology Molecular Diagnosis, Zibo Municipal Hospital, Zibo, China
| | - Tingting Lu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- *Correspondence: Tingting Lu
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11
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Shridhar A, Garg RK, Rizvi I, Jain M, Ali W, Malhotra HS, Kumar N, Sharma PK, Verma R, Uniyal R, Pandey S. Prevalence of primary immunodeficiency syndromes in tuberculous meningitis: A case-control study. J Infect Public Health 2021; 15:29-35. [PMID: 34883295 DOI: 10.1016/j.jiph.2021.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/18/2021] [Accepted: 11/25/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Only a proportion of patients with tuberculosis develop tuberculous meningitis. We hypothesize that inherent abnormalities in the host's innate or adaptive immune system may affect the outcome in tuberculous meningitis. In this study, we evaluated the proportion of underlying primary immunodeficiency in patients with tuberculous meningitis and its impact on the outcome. METHODS Newly-diagnosed cases with tuberculous meningitis and healthy controls were included. Patients with HIV disease were excluded. Blood specimen were subjected to immunological assessment to detect primary immunodeficiency syndrome/s. We estimated serum levels of IgG, IgA, IgM, IgE and IgD along with complement C3, C4, and C5 assay. Absolute lymphocyte count was obtained from an automated three-part cell counter. Flow cytometry was used to enumerate the following lymphocyte subsets: T Cell (CD3, CD4, CD8), B cell (CD19/CD20), and Natural killer cells (CD16 and CD56). Cases were followed for 6 months. Modified Barthel Index was used as a measure of disability. RESULTS We included 55 cases with tuberculous meningitis and 30 healthy controls. We notedthat among immune parameters, absolute lymphocyte count and CD4 T-cell count in the tuberculous meningitis group was lower; higher serum IgG levels were noted in the poor outcome group. On multivariate regression analysis, none of the immunological, clinical or radiological features were found to predict a poor outcome. CONCLUSION Host's immune factors contribute to the pathogenesis of tuberculous meningitis. Absolute lymphocyte count and CD4+ T-cell count were lower in tuberculous meningitis cases. Higher serum IgG levels may be associated with a poor outcome. A study with a larger sample size is needed to confirm our findings.
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Affiliation(s)
- Abhishek Shridhar
- Department of Neurology, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Ravindra Kumar Garg
- Department of Neurology, King George Medical University, Lucknow, Uttar Pradesh, India.
| | - Imran Rizvi
- Department of Neurology, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Mili Jain
- Department of Pathology, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Wahid Ali
- Department of Pathology, King George Medical University, Lucknow, Uttar Pradesh, India
| | | | - Neeraj Kumar
- Department of Neurology, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Praveen Kumar Sharma
- Department of Neurology, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Rajesh Verma
- Department of Neurology, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Ravi Uniyal
- Department of Neurology, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Shweta Pandey
- Department of Neurology, King George Medical University, Lucknow, Uttar Pradesh, India
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12
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van Toorn R, Zaharie SD, Seddon JA, van der Kuip M, Marceline van Furth A, Schoeman JF, Solomons RS. The use of thalidomide to treat children with tuberculosis meningitis: A review. Tuberculosis (Edinb) 2021; 130:102125. [PMID: 34500217 DOI: 10.1016/j.tube.2021.102125] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/26/2021] [Accepted: 09/02/2021] [Indexed: 11/17/2022]
Abstract
Much of the morbidity and mortality caused by tuberculous meningitis (TBM) is mediated by a dysregulated immune response. Effective host-directed therapy is therefore critical to improve survival and clinical outcomes. Currently only one host-directed therapy (HDT), corticosteroids, is proven to improve mortality. However, there is no evidence that corticosteroids reduce morbidity and the mechanism of action for mortality reduction is uncertain. Further, it has no proven benefit in HIV co-infected individuals. One promising host-directed therapy approach is to restrict the immunopathology arising from tumour necrosis factor (TNF)-α excess is via TNF-α inhibitors. There are accumulating data on the role of thalidomide, anti-TNF-α monoclonal antibodies (infliximab, adalimumab) and the soluble TNF-α receptor (etanercept) in TBM treatment. Thalidomide was developed nearly seventy years ago and has been a highly controversial drug. Birth defects and toxic adverse effects have limited its use but an improved understanding of its immunological mechanism of action suggest that it may have a crucial role in regulating the destructive host response seen in inflammatory conditions such as TBM. Observational studies at our institution found low dosage adjunctive thalidomide safe in treating tuberculous mass lesions and blindness related to optochiasmatic arachnoiditis, with good clinical and radiological response. In this review, we discuss possible mechanisms of action for thalidomide, based on our clinico-radiologic experience and post-mortem histopathological work. We also propose a rationale for its use in the treatment of certain TBM-related complications.
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Affiliation(s)
- Ronald van Toorn
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Stefan-Dan Zaharie
- Department of Anatomical Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; National Health Laboratory Services, South Africa
| | - James A Seddon
- Department of Infectious Disease, Imperial College London, United Kingdom; Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Martijn van der Kuip
- Department of Pediatric Infectious Diseases and Immunology, Amsterdam Infection & Immunity Institute, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - A Marceline van Furth
- Department of Pediatric Infectious Diseases and Immunology, Amsterdam Infection & Immunity Institute, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Johan F Schoeman
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Regan S Solomons
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
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13
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Briner M, Oberholzer M, Wagner F, Chan A. Potential disease trigger as a therapeutic option: infliximab for paradoxical reaction in tuberculosis of the central nervous system. BMJ Case Rep 2021; 14:14/8/e235511. [PMID: 34340991 PMCID: PMC8330559 DOI: 10.1136/bcr-2020-235511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 36-year-old man of central Asian origin was diagnosed with subacute disseminated tuberculosis. Initially, central nervous system involvement was suggested by an encephalopathic condition and MRI showing extensive basal and spinal meningitis. After initiation of anti-tuberculosis drugs and corticosteroid therapy, clinical and radiological deterioration of spinal damage was noted. We interpreted this in the context of a paradoxical reaction, which is suggested to be an overshooting inflammatory response after reconstitution of the immune system. Despite increased dosage of corticosteroids, a gradual worsening of gait ataxia over several weeks was noted. After administration of infliximab, the patient's condition progressively improved.
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Affiliation(s)
- Myriam Briner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Michael Oberholzer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Franca Wagner
- Diagnostic and Interventional Neuroradiology, Inselspital University Hospital Bern, 3010 Bern, Switzerland
| | - Andrew Chan
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
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14
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Post A, Kaboré B, Berendsen M, Diallo S, Traore O, Arts RJW, Netea MG, Joosten LAB, Tinto H, Jacobs J, de Mast Q, van der Ven A. Altered Ex-Vivo Cytokine Responses in Children With Asymptomatic Plasmodium falciparum Infection in Burkina Faso: An Additional Argument to Treat Asymptomatic Malaria? Front Immunol 2021; 12:614817. [PMID: 34177883 PMCID: PMC8220162 DOI: 10.3389/fimmu.2021.614817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 05/17/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction Patients with clinical malaria have an increased risk for bacterial bloodstream infections. We hypothesized that asymptomatic malaria parasitemia increases susceptibility for bacterial infections through an effect on the innate immune system. We measured circulating cytokine levels and ex-vivo cytokine production capacity in asymptomatic malaria and compared with controls. Methods Data were collected from asymptomatic participants <5 years old with and without positive malaria microscopy, as well as from hospitalized patients <5 years old with clinical malaria, bacteremia, or malaria/bacteremia co-infections in a malaria endemic region of Burkina Faso. Circulating cytokines (TNF-α, IFN-γ, IL-6, IL-10) were measured using multiplex assays. Whole blood from asymptomatic participants with and without positive malaria microscopy were ex-vivo stimulated with S. aureus, E. coli LPS and Salmonella Typhimurium; cytokine concentrations (TNF-α, IFN-γ, IL-1β, IL-6, IL-10) were measured on supernatants using ELISA. Results Included were children with clinical malaria (n=118), bacteremia (n=22), malaria and bacteremia co-infection (n=9), asymptomatic malaria (n=125), and asymptomatic controls (n=237). Children with either clinical or asymptomatic malaria had higher plasma cytokine concentrations than controls. Cytokine concentrations correlated positively with malaria parasite density with the strongest correlation for IL-10 in both asymptomatic (r=0.63) and clinical malaria (r=0.53). Patients with bacteremia had lower circulating IL-10, TNF-α and IFN-γ and higher IL-6 concentrations, compared to clinical malaria. Ex-vivo whole blood cytokine production to LPS and S. aureus was significantly lower in asymptomatic malaria compared to controls. Whole blood IFN-γ and IL-10 production in response to Salmonella was also lower in asymptomatic malaria. Interpretation In children with asymptomatic malaria, cytokine responses upon ex-vivo bacterial stimulation are downregulated. Further studies are needed to explore if the suggested impaired innate immune response to bacterial pathogens also translates into impaired control of pathogens such as Salmonella spp.
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Affiliation(s)
- Annelies Post
- Department of Internal Medicine, Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Berenger Kaboré
- Department of Internal Medicine, Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Nijmegen, Netherlands.,IRSS/Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | - Mike Berendsen
- Department of Internal Medicine, Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Nijmegen, Netherlands.,Bandim Health Project, Institute of Clinical Research, University of Southern Denmark and Odense University Hospital, Odense, Denmark
| | - Salou Diallo
- IRSS/Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | - Ousmane Traore
- IRSS/Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | - Rob J W Arts
- Department of Internal Medicine, Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Mihai G Netea
- Department of Internal Medicine, Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Nijmegen, Netherlands.,Department for Genomics & Immunoregulation, Life and Medical Sciences Institute (LIMES), University of Bonn, Bonn, Germany
| | - Leo A B Joosten
- Department of Internal Medicine, Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Halidou Tinto
- IRSS/Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso.,Institut Supérieur des Sciences de la Santé, Université Nazi Boni de Bobo-Dioulasso, Bobo-Dioulasso, Burkina Faso
| | - Jan Jacobs
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.,Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Quirijn de Mast
- Department of Internal Medicine, Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Nijmegen, Netherlands
| | - André van der Ven
- Department of Internal Medicine, Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Nijmegen, Netherlands
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15
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Abstract
PURPOSE OF REVIEW Central nervous system (CNS) tuberculosis is the most devastating form of tuberculosis (TB), with mortality and or neurological sequelae in over half of individuals. We reviewed original research and systematic reviews published since 1 January 2019 for new developments in CNS TB pathophysiology, diagnosis, management and prognosis. RECENT FINDINGS Insight in the pathophysiology is increasing steadily since the landmark studies in 1933, focussing on granuloma type classification, the relevance of the M. tuberculosis bacterial burden and the wide range of immunological responses. Although Xpert/RIF has been recommended by the WHO for extrapulmonary TB diagnosis, culture is still needed to increase the sensitivity of TB meningitis diagnosis. Sequential MRIs can improve understanding of neurological deficits at baseline and during treatment. Pharmacokinetic/pharmacodynamic modelling suggests that higher doses of rifampicin and isoniazid in TB meningitis could improve survival. SUMMARY Recent studies in the field of CNS-TB have largely focussed on TB meningitis. The outcome may improve by optimizing treatment dosing. This needs to be confirmed in clinical trials. Due to the important role of inflammation, these trials should be used as the platform to study the inflammatory and metabolomic responses. This could improve understanding of the biology of this disease and improve patient outlook by enabling individualised host-directed therapy.
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Affiliation(s)
- Sofiati Dian
- Department of Neurology, Faculty of Medicine, Universitas Padjdjaran/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
- Infectious Disease Research Center, Faculty of Medicine, Padjadjaran University/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Ahmad Rizal Ganiem
- Department of Neurology, Faculty of Medicine, Universitas Padjdjaran/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
- Infectious Disease Research Center, Faculty of Medicine, Padjadjaran University/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Arjan van Laarhoven
- Department of Internal Medicine Radboud University Medical Center, Nijmegen, the Netherlands
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16
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Phenotype of Peripheral NK Cells in Latent, Active, and Meningeal Tuberculosis. J Immunol Res 2021; 2021:5517856. [PMID: 34007850 PMCID: PMC8100419 DOI: 10.1155/2021/5517856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 04/08/2021] [Accepted: 04/16/2021] [Indexed: 01/13/2023] Open
Abstract
The mechanisms underlying the immunopathology of tuberculous meningitis (TBM), the most severe clinical form of extrapulmonary tuberculosis (TB), are not understood. It is currently believed that the spread of Mycobacterium tuberculosis (Mtb) from the lung is an early event that occurs before the establishment of adaptive immunity. Hence, several innate immune mechanisms may participate in the containment of Mtb infection and prevent extrapulmonary disease manifestations. Natural killer (NK) cells participate in defensive processes that distinguish latent TB infection (LTBI) from active pulmonary TB (PTB). However, their role in TBM is unknown. Here, we performed a cross-sectional analysis of circulating NK cellCID="C008" value="s" phenotype in a prospective cohort of TBM patients (n = 10) using flow cytometry. Also, we addressed the responses of memory-like NK cell subpopulations to the contact with Mtb antigens in vitro. Finally, we determined plasma levels of soluble NKG2D receptor ligands in our cohort of TBM patients by enzyme-linked immunosorbent assay (ELISA). Our comparative groups consisted of individuals with LTBI (n = 11) and PTB (n = 27) patients. We found that NK cells from TBM patients showed lower absolute frequencies, higher CD69 expression, and poor expansion of the CD45RO+ memory-like subpopulation upon Mtb exposure in vitro compared to LTBI individuals. In addition, a reduction in the frequency of CD56brightCD16− NK cells characterized TBM patients but not LTBI or PTB subjects. Our study expands on earlier reports about the role of NK cells in TBM showing a reduced frequency of cytokine-producing cells compared to LTBI and PTB.
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17
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Tuberculous Meningitis: Pathogenesis, Immune Responses, Diagnostic Challenges, and the Potential of Biomarker-Based Approaches. J Clin Microbiol 2021; 59:JCM.01771-20. [PMID: 33087432 PMCID: PMC8106718 DOI: 10.1128/jcm.01771-20] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Tuberculous meningitis (TBM) is the most devastating form of tuberculosis (TB), causing high mortality or disability. Clinical management of the disease is challenging due to limitations of the existing diagnostic approaches. Our knowledge on the immunology and pathogenesis of the disease is currently limited. More research is urgently needed to enhance our understanding of the immunopathogenesis of the disease and guide us toward the identification of targets that may be useful for vaccines or host-directed therapeutics. Tuberculous meningitis (TBM) is the most devastating form of tuberculosis (TB), causing high mortality or disability. Clinical management of the disease is challenging due to limitations of the existing diagnostic approaches. Our knowledge on the immunology and pathogenesis of the disease is currently limited. More research is urgently needed to enhance our understanding of the immunopathogenesis of the disease and guide us toward the identification of targets that may be useful for vaccines or host-directed therapeutics. In this review, we summarize the current knowledge about the immunology and pathogenesis of TBM and summarize the literature on existing and new, especially biomarker-based, approaches that may be useful in the management of TBM. We identify research gaps and provide directions for research which may lead to the development of new tools for the control of the disease in the near future.
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18
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Cresswell FV, Davis AG, Sharma K, Basu Roy R, Ganiem AR, Kagimu E, Solomons R, Wilkinson RJ, Bahr NC, Thuong NTT. Recent Developments in Tuberculous Meningitis Pathogenesis and Diagnostics. Wellcome Open Res 2021; 4:164. [PMID: 33364436 PMCID: PMC7739117 DOI: 10.12688/wellcomeopenres.15506.3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2021] [Indexed: 12/13/2022] Open
Abstract
The pathogenesis of Tuberculous meningitis (TBM) is poorly understood, but contemporary molecular biology technologies have allowed for recent improvements in our understanding of TBM. For instance, neutrophils appear to play a significant role in the immunopathogenesis of TBM, and either a paucity or an excess of inflammation can be detrimental in TBM. Further, severity of HIV-associated immunosuppression is an important determinant of inflammatory response; patients with the advanced immunosuppression (CD4+ T-cell count of <150 cells/μL) having higher CSF neutrophils, greater CSF cytokine concentrations and higher mortality than those with CD4+ T-cell counts > 150 cells/μL. Host genetics may also influence outcomes with LT4AH genotype predicting inflammatory phenotype, steroid responsiveness and survival in Vietnamese adults with TBM. Whist in Indonesia, CSF tryptophan level was a predictor of survival, suggesting tryptophan metabolism may be important in TBM pathogenesis. These varying responses mean that we must consider whether a "one-size-fits-all" approach to anti-bacillary or immunomodulatory treatment in TBM is truly the best way forward. Of course, to allow for proper treatment, early and rapid diagnosis of TBM must occur. Diagnosis has always been a challenge but the field of TB diagnosis is evolving, with sensitivities of at least 70% now possible in less than two hours with GeneXpert MTB/Rif Ultra. In addition, advanced molecular techniques such as CRISPR-MTB and metagenomic next generation sequencing may hold promise for TBM diagnosis. Host-based biomarkers and signatures are being further evaluated in childhood and adult TBM as adjunctive biomarkers as even with improved molecular assays, cases are still missed. A better grasp of host and pathogen behaviour may lead to improved diagnostics, targeted immunotherapy, and possibly biomarker-based, patient-specific treatment regimens.
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Affiliation(s)
- Fiona V Cresswell
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Research Department, Infectious Diseases Institute, Kampala, PO Box 22418, Uganda
- MRC-UVRI-London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Angharad G. Davis
- University College London, London, WC1E6BT, UK
- Francis Crick Institute, London, NW1 1AT, UK
- Department of Medicine, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, 7925, South Africa
| | - Kusum Sharma
- Department of Medical Microbiology, Post-graduate Department of Medical Education and Research, Chandigahr, India
| | - Robindra Basu Roy
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Ahmad Rizal Ganiem
- Department of Neurology, Hasan Sadikin Hospital, Faculty of Medicine. Universitas Padjadjaran, Bandung, Indonesia
| | - Enock Kagimu
- Research Department, Infectious Diseases Institute, Kampala, PO Box 22418, Uganda
| | - Regan Solomons
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | - Robert J. Wilkinson
- Francis Crick Institute, London, NW1 1AT, UK
- Department of Medicine, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, 7925, South Africa
- Department of Infectious Diseases, Imperial College, London, W2 1PG, UK
| | - Nathan C Bahr
- Division of Infectious Diseases. Department of Medicine., University of Kansas, Kansas City, USA
| | | | - Tuberculous Meningitis International Research Consortium
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Research Department, Infectious Diseases Institute, Kampala, PO Box 22418, Uganda
- MRC-UVRI-London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- University College London, London, WC1E6BT, UK
- Francis Crick Institute, London, NW1 1AT, UK
- Department of Medicine, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, 7925, South Africa
- Department of Medical Microbiology, Post-graduate Department of Medical Education and Research, Chandigahr, India
- Department of Neurology, Hasan Sadikin Hospital, Faculty of Medicine. Universitas Padjadjaran, Bandung, Indonesia
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
- Department of Infectious Diseases, Imperial College, London, W2 1PG, UK
- Division of Infectious Diseases. Department of Medicine., University of Kansas, Kansas City, USA
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
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19
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Koeken VACM, Ganiem AR, Dian S, Ruslami R, Chaidir L, Netea MG, Kumar V, Alisjahbana B, van Crevel R, van Laarhoven A. Cerebrospinal fluid IL-1β is elevated in tuberculous meningitis patients but not associated with mortality. Tuberculosis (Edinb) 2020; 126:102019. [PMID: 33202351 DOI: 10.1016/j.tube.2020.102019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/04/2020] [Accepted: 11/08/2020] [Indexed: 01/21/2023]
Abstract
Inflammation contributes to the pathophysiology and high mortality of tuberculous meningitis. The IL-1β pathway has been implicated in immunopathology and could be a target for host-directed therapy. IL-1β was elevated in the cerebrospinal fluid (CSF) of 225 HIV-uninfected tuberculous meningitis patients in Indonesia compared to controls, but did not predict subsequent mortality, nor did IL-6 or IL-1Ra. Furthermore, genetic loci known to regulate IL1B gene expression did not predict mortality in 443 tuberculous meningitis patients, although two of these loci did predict CSF IL-1β concentrations. Collectively, these data argue against a role for IL-1β targeted host-directed therapy in tuberculous meningitis.
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Affiliation(s)
- Valerie A C M Koeken
- Department of Internal Medicine and Radboud Center for Infectious Diseases (RCI), Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, the Netherlands; Department of Computational Biology for Individualised Infection Medicine, Centre for Individualised Infection Medicine (CiiM) & TWINCORE, Joint Ventures Between the Helmholtz-Centre for Infection Research (HZI) and the Hannover Medical School (MHH), 30625 Hannover, Germany
| | - Ahmad R Ganiem
- TB-HIV Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Sofiati Dian
- TB-HIV Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Rovina Ruslami
- TB-HIV Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Lidya Chaidir
- TB-HIV Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Mihai G Netea
- Department of Internal Medicine and Radboud Center for Infectious Diseases (RCI), Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, the Netherlands; Department for Genomics & Immunoregulation, Life and Medical Sciences Institute (LIMES), University of Bonn, 53115 Bonn, Germany
| | - Vinod Kumar
- Department of Internal Medicine and Radboud Center for Infectious Diseases (RCI), Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, the Netherlands; Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Bachti Alisjahbana
- TB-HIV Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Reinout van Crevel
- Department of Internal Medicine and Radboud Center for Infectious Diseases (RCI), Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, the Netherlands; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Arjan van Laarhoven
- Department of Internal Medicine and Radboud Center for Infectious Diseases (RCI), Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, the Netherlands.
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20
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Cresswell FV, Davis AG, Sharma K, Basu Roy R, Ganiem AR, Kagimu E, Solomons R, Wilkinson RJ, Bahr NC, Thuong NTT. Recent Developments in Tuberculous Meningitis Pathogenesis and Diagnostics. Wellcome Open Res 2020; 4:164. [PMID: 33364436 PMCID: PMC7739117 DOI: 10.12688/wellcomeopenres.15506.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2020] [Indexed: 12/15/2022] Open
Abstract
The pathogenesis of Tuberculous meningitis (TBM) is poorly understood, but contemporary molecular biology technologies have allowed for recent improvements in our understanding of TBM. For instance, neutrophils appear to play a significant role in the immunopathogenesis of TBM, and either a paucity or an excess of inflammation can be detrimental in TBM. Further, severity of HIV-associated immunosuppression is an important determinant of inflammatory response; patients with the advanced immunosuppression (CD4+ T-cell count of <150 cells/μL) having higher CSF neutrophils, greater CSF cytokine concentrations and higher mortality than those with CD4+ T-cell counts > 150 cells/μL. Host genetics may also influence outcomes with LT4AH genotype predicting inflammatory phenotype, steroid responsiveness and survival in Vietnamese adults with TBM. Whist in Indonesia, CSF tryptophan level was a predictor of survival, suggesting tryptophan metabolism may be important in TBM pathogenesis. These varying responses mean that we must consider whether a "one-size-fits-all" approach to anti-bacillary or immunomodulatory treatment in TBM is truly the best way forward. Of course, to allow for proper treatment, early and rapid diagnosis of TBM must occur. Diagnosis has always been a challenge but the field of TB diagnosis is evolving, with sensitivities of at least 70% now possible in less than two hours with GeneXpert MTB/Rif Ultra. In addition, advanced molecular techniques such as CRISPR-MTB and metagenomic next generation sequencing may hold promise for TBM diagnosis. Host-based biomarkers and signatures are being further evaluated in childhood and adult TBM as adjunctive biomarkers as even with improved molecular assays, cases are still missed. A better grasp of host and pathogen behaviour may lead to improved diagnostics, targeted immunotherapy, and possibly biomarker-based, patient-specific treatment regimens.
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Affiliation(s)
- Fiona V Cresswell
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Research Department, Infectious Diseases Institute, Kampala, PO Box 22418, Uganda
- MRC-UVRI-London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Angharad G. Davis
- University College London, London, WC1E6BT, UK
- Francis Crick Institute, London, NW1 1AT, UK
- Department of Medicine, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, 7925, South Africa
| | - Kusum Sharma
- Department of Medical Microbiology, Post-graduate Department of Medical Education and Research, Chandigahr, India
| | - Robindra Basu Roy
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Ahmad Rizal Ganiem
- Department of Neurology, Hasan Sadikin Hospital, Faculty of Medicine. Universitas Padjadjaran, Bandung, Indonesia
| | - Enock Kagimu
- Research Department, Infectious Diseases Institute, Kampala, PO Box 22418, Uganda
| | - Regan Solomons
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | - Robert J. Wilkinson
- Francis Crick Institute, London, NW1 1AT, UK
- Department of Medicine, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, 7925, South Africa
- Department of Infectious Diseases, Imperial College, London, W2 1PG, UK
| | - Nathan C Bahr
- Division of Infectious Diseases. Department of Medicine., University of Kansas, Kansas City, USA
| | | | - Tuberculous Meningitis International Research Consortium
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Research Department, Infectious Diseases Institute, Kampala, PO Box 22418, Uganda
- MRC-UVRI-London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- University College London, London, WC1E6BT, UK
- Francis Crick Institute, London, NW1 1AT, UK
- Department of Medicine, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, 7925, South Africa
- Department of Medical Microbiology, Post-graduate Department of Medical Education and Research, Chandigahr, India
- Department of Neurology, Hasan Sadikin Hospital, Faculty of Medicine. Universitas Padjadjaran, Bandung, Indonesia
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
- Department of Infectious Diseases, Imperial College, London, W2 1PG, UK
- Division of Infectious Diseases. Department of Medicine., University of Kansas, Kansas City, USA
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
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21
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Rohlwink UK, Chow FC, Wasserman S, Dian S, Lai RPJ, Chaidir L, Hamers RL, Wilkinson RJ, Boulware DR, Cresswell FV, van Laarhoven A. Standardized approaches for clinical sampling and endpoint ascertainment in tuberculous meningitis studies. Wellcome Open Res 2020; 4:204. [PMID: 32399496 PMCID: PMC7194504 DOI: 10.12688/wellcomeopenres.15497.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2020] [Indexed: 01/12/2023] Open
Abstract
Tuberculous meningitis (TBM), the most severe manifestation of tuberculosis, has poorly understood immunopathology and high mortality and morbidity despite antituberculous therapy. This calls for accelerated clinical and basic science research in this field. As TBM disproportionally affects poorer communities, studies are often performed in resource-limited environments, creating challenges for data collection and harmonisation. Comparison of TBM studies has been hampered by variation in sampling strategies, study design and choice of study endpoints. Based on literature review and expert consensus, this paper provides firstly, practical recommendations to enable thorough diagnostic, pathophysiological and pharmacokinetic studies using clinical samples, and facilitates better data aggregation and comparisons across populations and settings. Secondly, we discuss clinically relevant study endpoints, including neuroimaging, functional outcome, and cause of death, with suggestions of how these could be applied in different designs for future TBM studies.
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Affiliation(s)
- Ursula K Rohlwink
- Division of Neurosurgery, Department of Surgery, Neuroscience Institute, University of Cape Town, Cape Town, 7700, South Africa
| | - Felicia C Chow
- Weill Institute for Neurosciences and Departments of Neurology and Medicine (Infectious Diseases), University of California, San Francisco, USA
| | - Sean Wasserman
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory, Cape Town, South Africa
| | - Sofiati Dian
- Infectious Disease Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia,Department of Neurology, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin Hospital, Bandung, Indonesia
| | - Rachel PJ Lai
- The Francis Crick Institute, Midland Road, London, NW1 1AT, UK,Department of Infectious Diseases, Imperial College London, London, UK
| | - Lidya Chaidir
- Infectious Disease Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia,Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Raph L Hamers
- Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia,Faculty of Medicine, University of Indonesia, Jakarta, Indonesia,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Robert J Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory, Cape Town, South Africa,The Francis Crick Institute, Midland Road, London, NW1 1AT, UK,Department of Infectious Diseases, Imperial College London, London, UK
| | | | - Fiona V Cresswell
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK,Infectious Disease Institute, Mulago College of Health Sciences, Kampala, Uganda,MRC-UVRI LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Arjan van Laarhoven
- Department of Internal Medicine and Radboud Center of Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands,
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22
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Rohlwink UK, Chow FC, Wasserman S, Dian S, Lai RPJ, Chaidir L, Hamers RL, Wilkinson RJ, Boulware DR, Cresswell FV, van Laarhoven A. Standardized approaches for clinical sampling and endpoint ascertainment in tuberculous meningitis studies. Wellcome Open Res 2020; 4:204. [PMID: 32399496 PMCID: PMC7194504 DOI: 10.12688/wellcomeopenres.15497.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2019] [Indexed: 12/26/2022] Open
Abstract
Tuberculous meningitis (TBM), the most severe manifestation of tuberculosis, has poorly understood immunopathology and high mortality and morbidity despite antituberculous therapy. This calls for accelerated clinical and basic science research in this field. As TBM disproportionally affects poorer communities, studies are often performed in resource-limited environments, creating challenges for data collection and harmonisation. Comparison of TBM studies has been hampered by variation in sampling strategies, study design and choice of study endpoints. Based on literature review and expert consensus, this paper provides firstly, practical recommendations to enable thorough diagnostic, pathophysiological and pharmacokinetic studies using clinical samples, and facilitates better data aggregation and comparisons across populations and settings. Secondly, we discuss clinically relevant study endpoints, including neuroimaging, functional outcome, and cause of death, with suggestions of how these could be applied in different designs for future TBM studies.
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Affiliation(s)
- Ursula K Rohlwink
- Division of Neurosurgery, Department of Surgery, Neuroscience Institute, University of Cape Town, Cape Town, 7700, South Africa
| | - Felicia C Chow
- Weill Institute for Neurosciences and Departments of Neurology and Medicine (Infectious Diseases), University of California, San Francisco, USA
| | - Sean Wasserman
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory, Cape Town, South Africa
| | - Sofiati Dian
- Infectious Disease Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia,Department of Neurology, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin Hospital, Bandung, Indonesia
| | - Rachel PJ Lai
- The Francis Crick Institute, Midland Road, London, NW1 1AT, UK,Department of Infectious Diseases, Imperial College London, London, UK
| | - Lidya Chaidir
- Infectious Disease Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia,Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Raph L Hamers
- Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia,Faculty of Medicine, University of Indonesia, Jakarta, Indonesia,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Robert J Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory, Cape Town, South Africa,The Francis Crick Institute, Midland Road, London, NW1 1AT, UK,Department of Infectious Diseases, Imperial College London, London, UK
| | | | - Fiona V Cresswell
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK,Infectious Disease Institute, Mulago College of Health Sciences, Kampala, Uganda,MRC-UVRI LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Arjan van Laarhoven
- Department of Internal Medicine and Radboud Center of Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands,
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23
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O'Brien P, Vinnard C, Subbian S. An improved protocol to establish experimental tuberculous meningitis in the rabbit. MethodsX 2020; 7:100832. [PMID: 32195146 PMCID: PMC7078415 DOI: 10.1016/j.mex.2020.100832] [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: 09/05/2019] [Accepted: 02/14/2020] [Indexed: 11/21/2022] Open
Abstract
Tuberculous meningitis (TBM), caused by Mycobacterium tuberculosis (Mtb), is the deadliest form of tuberculosis in humans, particularly in children and the geriatric population. However, the host-pathogen interactions underlying TBM is not well understood. Rabbits are a valuable model system to study TB in humans. The rabbit model of TB recapitulates several pathophysiological characteristics, including heterogeneity, architecture, and development of granulomas at the site of infection as observed in Mtb-infected human organs. Previously, our group has established a rabbit model of TBM that has been used to understand the host immune response to Mtb infection and to evaluate novel intervention therapies for TBM. In this model, rabbits infected intracisternally with Mtb showed histopathologic manifestations in the brain and meninges that are hallmarks of TBM in humans, including inflammatory cell accumulation and thickening of the leptomeninges. However, in this model, a helmet made of dental acrylic was attached to rabbit's skull with screws under anesthesia. At 24 h post-procedure, the animals were injected intracisternally with Mtb using a spinal needle. The rabbits were necropsied at various experimental time points up to 2 weeks post-infection. Although this method has been successful in establishing TBM, placement of the dental acrylic helmet on rabbit skull with screws that stays until the experimental endpoint poses stress to the animals and increases the chances of secondary infection. To alleviate these issues, we have developed an improved protocol, in which sedated rabbits are placed on specialised stereotaxic equipment and injected with Mtb intracisternally. This method is less cumbersome, faster, and more efficient in delivering the bacteria. Besides, the animals are not stressed by this method, compared to the previous one.
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Affiliation(s)
- Paul O'Brien
- Department of Radiation Oncology, Division of Cancer Biology, United States
| | - Christopher Vinnard
- Public Health Research Institute of New Jersey Medical School, United States
| | - Selvakumar Subbian
- Public Health Research Institute of New Jersey Medical School, United States
- Corresponding author.
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24
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Chen Y, Liu X, Zhang X, Zhang Z, Zhou X, Wang Y, Wu S, Zheng L. Longitudinal cerebrospinal fluid assessment in a patient with tuberculous meningitis-A case report. J Clin Lab Anal 2020; 34:e23286. [PMID: 32159262 PMCID: PMC7370724 DOI: 10.1002/jcla.23286] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 02/09/2020] [Accepted: 02/16/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Dynamic assessment of cerebrospinal fluid (CSF) is essential for diagnosis, treatment, and prognosis of tuberculous meningitis, one of the most severe forms of central nervous system (CNS) infection. CASE PRESENTATION A 45-year-old man sought care as he developed confusion, clonic convulsion, and coma. Longitudinal, comprehensive analyses of cytological, biochemical, and microbial changes in CSF specimen were assessed for this patient. On day 1 of hospitalization, modified Ziehl-Neelsen staining of CSF identified positive acid-fast bacilli, cytological analysis revealed neutrophilic-predominant pleocytosis (neutrophils 77%), and adenosine deaminase (ADA) was substantially elevated. Therefore, tuberculous meningitis was diagnosed and first-line standard anti-tuberculosis treatment was initiated. Interestingly, after 7-day treatment, the patient was greatly improved, and CSF disclosed a dominant percentage of lymphocytes (82%) as well as macrophages engulfing Mycobacterium tuberculosis. Later, the dose of dexamethasone was reduced, large number of neutrophils (57%) was present and protein level was immediately elevated in CSF specimen, indicating a possible relapse of tuberculous meningitis. Since the clinical condition of the patient was not worsening, the patient was stick to reduced dose of dexamethasone and standard anti-tuberculosis agents. He was discharged from the hospital on day 34, with 1-year continuation standard anti-tuberculosis therapy, and was clinically resolved from tuberculous meningitis. CONCLUSION Detailed analyses of cellular composition, biochemical results, and microbial tests of CSF specimen provide the physician direct evidence of the immune surveillance status during tuberculous meningitis, which facilitates early diagnosis, optimal treatment, and improved prognosis.
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Affiliation(s)
- Yuxin Chen
- Department of Laboratory Medicine, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
| | - Xiaojin Liu
- Department of Infectious Disease, Fifth Hospital of Shijiazhuang, Shijiazhuang, China
| | - Xun Zhang
- Department of Laboratory Medicine, Chest Hospital of Hebei Province, Shijiazhuang, China
| | - Zhihua Zhang
- Department of Laboratory Medicine, Chest Hospital of Hebei Province, Shijiazhuang, China
| | - Xueqin Zhou
- Department of Laboratory Medicine, Chest Hospital of Hebei Province, Shijiazhuang, China
| | - Yuqing Wang
- Department of Respiratory Medicine, No.4 people's hospital of Qinghai Province, Xining, China
| | - Shucai Wu
- Department of Tuberculosis, Chest Hospital of Hebei Province, Shijiazhuang, China
| | - Liheng Zheng
- Department of Laboratory Medicine, Chest Hospital of Hebei Province, Shijiazhuang, China
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25
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Kumar R, Kolloli A, Singh P, Vinnard C, Kaplan G, Subbian S. Thalidomide and Phosphodiesterase 4 Inhibitors as Host Directed Therapeutics for Tuberculous Meningitis: Insights From the Rabbit Model. Front Cell Infect Microbiol 2020; 9:450. [PMID: 32010638 PMCID: PMC6972508 DOI: 10.3389/fcimb.2019.00450] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 12/12/2019] [Indexed: 01/15/2023] Open
Abstract
Tuberculous meningitis (TBM) is the most devastating form of extrapulmonary Mycobacterium tuberculosis infection in humans. Severe inflammation and extensive tissue damage drive the morbidity and mortality of this manifestation of tuberculosis (TB). Antibiotic treatment is ineffective at curing TBM due to variable and incomplete drug penetration across the blood-brain barrier (BBB) and blood-cerebrospinal fluid (CSF) barriers. Adjunctive corticosteroid therapy, used to dampen the inflammation, and the pathologic manifestation of TBM, improves overall survival but does not entirely prevent the morbidity of the disease and has significant toxicities, including immune-suppression. The rabbit has served as a fit for purpose experimental model of human TBM since the early 1900s due to the similarity in the developmental processes of the brain, including neuronal development, myelination, and microglial functions between humans and rabbits. Consistent with the observations made in humans, proinflammatory cytokines, including TNF-α, play a critical role in the pathogenesis of TBM in rabbits focusing the attention on the utility of TNF-α inhibitors in treating the disease. Thalidomide, an inhibitor of monocyte-derived TNF-α, was evaluated in the rabbit model of TBM and shown to improve survival and reduce inflammation of the brain and the meninges. Clinical studies in humans have also shown a beneficial response to thalidomide. However, the teratogenicity and T-cell activation function of the drug limit the use of thalidomide in the clinic. Thus, new drugs with more selective anti-inflammatory properties and a better safety profile are being developed. Some of these candidate drugs, such as phosphodiesterase-4 inhibitors, have been shown to reduce the morbidity and increase the survival of rabbits with TBM. Future studies are needed to assess the beneficial effects of these drugs for their potential to improve the current treatment strategy for TBM in humans.
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Affiliation(s)
- Ranjeet Kumar
- New Jersey Medical School, Rutgers, Public Health Research Institute, The State University of New Jersey, Newark, NJ, United States
| | - Afsal Kolloli
- New Jersey Medical School, Rutgers, Public Health Research Institute, The State University of New Jersey, Newark, NJ, United States
| | - Pooja Singh
- New Jersey Medical School, Rutgers, Public Health Research Institute, The State University of New Jersey, Newark, NJ, United States
| | - Christopher Vinnard
- New Jersey Medical School, Rutgers, Public Health Research Institute, The State University of New Jersey, Newark, NJ, United States
| | - Gilla Kaplan
- University of Cape Town, Cape Town, South Africa
| | - Selvakumar Subbian
- New Jersey Medical School, Rutgers, Public Health Research Institute, The State University of New Jersey, Newark, NJ, United States
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26
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Cresswell FV, Davis AG, Sharma K, Basu Roy R, Ganiem AR, Kagimu E, Solomons R, Wilkinson RJ, Bahr NC, Thuong NTT. Recent Developments in Tuberculous Meningitis Pathogenesis and Diagnostics. Wellcome Open Res 2019; 4:164. [PMID: 33364436 PMCID: PMC7739117 DOI: 10.12688/wellcomeopenres.15506.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2019] [Indexed: 12/15/2022] Open
Abstract
The pathogenesis of Tuberculous meningitis (TBM) is poorly understood, but contemporary molecular biology technologies have allowed for recent improvements in our understanding of TBM. For instance, neutrophils appear to play a significant role in the immunopathogenesis of TBM, and either a paucity or an excess of inflammation can be detrimental in TBM. Further, severity of HIV-associated immunosuppression is an important determinant of inflammatory response; patients with the advanced immunosuppression (CD4+ T-cell count of <150 cells/μL) having higher CSF neutrophils, greater CSF cytokine concentrations and higher mortality than those with CD4+ T-cell counts > 150 cells/μL. Host genetics may also influence outcomes with LT4AH genotype predicting inflammatory phenotype, steroid responsiveness and survival in Vietnamese adults with TBM. Whist in Indonesia, CSF tryptophan level was a predictor of survival, suggesting tryptophan metabolism may be important in TBM pathogenesis. These varying responses mean that we must consider whether a "one-size-fits-all" approach to anti-bacillary or immunomodulatory treatment in TBM is truly the best way forward. Of course, to allow for proper treatment, early and rapid diagnosis of TBM must occur. Diagnosis has always been a challenge but the field of TB diagnosis is evolving, with sensitivities of at least 70% now possible in less than two hours with GeneXpert MTB/Rif Ultra. In addition, advanced molecular techniques such as CRISPR-MTB and metagenomic next generation sequencing may hold promise for TBM diagnosis. Host-based biomarkers and signatures are being further evaluated in childhood and adult TBM as adjunctive biomarkers as even with improved molecular assays, cases are still missed. A better grasp of host and pathogen behaviour may lead to improved diagnostics, targeted immunotherapy, and possibly biomarker-based, patient-specific treatment regimens.
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Affiliation(s)
- Fiona V Cresswell
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Research Department, Infectious Diseases Institute, Kampala, PO Box 22418, Uganda
- MRC-UVRI-London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Angharad G. Davis
- University College London, London, WC1E6BT, UK
- Francis Crick Institute, London, NW1 1AT, UK
- Department of Medicine, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, 7925, South Africa
| | - Kusum Sharma
- Department of Medical Microbiology, Post-graduate Department of Medical Education and Research, Chandigahr, India
| | - Robindra Basu Roy
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Ahmad Rizal Ganiem
- Department of Neurology, Hasan Sadikin Hospital, Faculty of Medicine. Universitas Padjadjaran, Bandung, Indonesia
| | - Enock Kagimu
- Research Department, Infectious Diseases Institute, Kampala, PO Box 22418, Uganda
| | - Regan Solomons
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | - Robert J. Wilkinson
- Francis Crick Institute, London, NW1 1AT, UK
- Department of Medicine, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, 7925, South Africa
- Department of Infectious Diseases, Imperial College, London, W2 1PG, UK
| | - Nathan C Bahr
- Division of Infectious Diseases. Department of Medicine., University of Kansas, Kansas City, USA
| | | | - Tuberculous Meningitis International Research Consortium
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Research Department, Infectious Diseases Institute, Kampala, PO Box 22418, Uganda
- MRC-UVRI-London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- University College London, London, WC1E6BT, UK
- Francis Crick Institute, London, NW1 1AT, UK
- Department of Medicine, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, 7925, South Africa
- Department of Medical Microbiology, Post-graduate Department of Medical Education and Research, Chandigahr, India
- Department of Neurology, Hasan Sadikin Hospital, Faculty of Medicine. Universitas Padjadjaran, Bandung, Indonesia
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
- Department of Infectious Diseases, Imperial College, London, W2 1PG, UK
- Division of Infectious Diseases. Department of Medicine., University of Kansas, Kansas City, USA
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
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