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Dupnik K, Rivera VR, Dorvil N, Duffus Y, Akbarnejad H, Gao Y, Liu J, Apollon A, Dumont E, Riviere C, Severe P, Lavoile K, Duran Mendicuti MA, Pierre S, Rouzier V, Walsh KF, Byrne AL, Joseph P, Cremieux PY, Pape JW, Koenig SP. Potential Utility of C-reactive Protein for Tuberculosis Risk Stratification Among Patients With Non-Meningitic Symptoms at HIV Diagnosis in Low- and Middle-income Countries. Open Forum Infect Dis 2024; 11:ofae356. [PMID: 39022393 PMCID: PMC11252845 DOI: 10.1093/ofid/ofae356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 06/27/2024] [Indexed: 07/20/2024] Open
Abstract
Background The World Health Organization recommends initiating same-day antiretroviral therapy (ART) while tuberculosis (TB) testing is under way for patients with non-meningitic symptoms at HIV diagnosis, though safety data are limited. C-reactive protein (CRP) testing may improve TB risk stratification in this population. Methods In this baseline analysis of 498 adults (>18 years) with TB symptoms at HIV diagnosis who were enrolled in a trial of rapid ART initiation in Haiti, we describe test characteristics of varying CRP thresholds in the diagnosis of TB. We also assessed predictors of high CRP as a continuous variable using generalized linear models. Results Eighty-seven (17.5%) participants were diagnosed with baseline TB. The median CRP was 33.0 mg/L (interquartile range: 5.1, 85.5) in those with TB, and 2.6 mg/L (interquartile range: 0.8, 11.7) in those without TB. As the CRP threshold increased from ≥1 mg/L to ≥10 mg/L, the positive predictive value for TB increased from 22.4% to 35.4% and negative predictive value decreased from 96.9% to 92.3%. With CRP thresholds varying from <1 to <10 mg/L, a range from 25.5% to 64.9% of the cohort would have been eligible for same-day ART and 0.8% to 5.0% would have untreated TB at ART initiation. Conclusions CRP concentrations can be used to improve TB risk stratification, facilitating same-day decisions about ART initiation. Depending on the CRP threshold, one-quarter to two-thirds of patients could be eligible for same-day ART, with a reduction of 3- to 20-fold in the proportion with untreated TB, compared with a strategy of same-day ART while awaiting TB test results.
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Affiliation(s)
- Kathryn Dupnik
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Vanessa R Rivera
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Nancy Dorvil
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Yanique Duffus
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | | | - Yipeng Gao
- The Analysis Group, Boston, Massachusetts, USA
| | - Jingyi Liu
- The Analysis Group, Boston, Massachusetts, USA
| | - Alexandra Apollon
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Emelyne Dumont
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Cynthia Riviere
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Patrice Severe
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Kerlyne Lavoile
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | - Samuel Pierre
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Vanessa Rouzier
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
- St. Vincent's Hospital and Clinical School, University of New South Wales, Darlinghurst, New South Wales, Australia
| | - Kathleen F Walsh
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Anthony L Byrne
- St. Vincent's Hospital and Clinical School, University of New South Wales, Darlinghurst, New South Wales, Australia
| | - Patrice Joseph
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | - Jean William Pape
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
- St. Vincent's Hospital and Clinical School, University of New South Wales, Darlinghurst, New South Wales, Australia
| | - Serena P Koenig
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Maenetje P, Baik Y, Schramm DB, Vangu MDTW, Wallis RS, Mlotshwa M, Tiemessen CT, Li Y, Kornfeld H, Churchyard G, Auld SC, Bisson GP. Circulating Biomarkers, Fraction of Exhaled Nitric Oxide, and Lung Function in Patients With Human Immunodeficiency Virus and Tuberculosis. J Infect Dis 2024; 229:824-832. [PMID: 37386883 PMCID: PMC10938205 DOI: 10.1093/infdis/jiad232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 05/12/2023] [Accepted: 06/27/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Identification of proinflammatory factors responding to Mycobacterium tuberculosis is important to reduce long-term sequelae of pulmonary tuberculosis (TB). METHODS We examined the association between plasma biomarkers, the fraction of exhaled nitric oxide (FeNO), and lung function among a prospective cohort of 105 adults newly diagnosed with TB/human immunodeficiency virus (HIV) in South Africa. Participants were followed for 48 weeks from antiretroviral therapy (ART) initiation with serial assessments of plasma biomarkers, FeNO, lung function, and respiratory symptoms. Linear regression and generalized estimating equations were used to examine the associations at baseline and over the course of TB treatment, respectively. RESULTS At baseline, higher FeNO levels were associated with preserved lung function, whereas greater respiratory symptoms and higher interleukin (IL)-6 plasma levels were associated with worse lung function. After ART and TB treatment initiation, improvements in lung function were associated with increases in FeNO (rate ratio [RR] = 86 mL, 95% confidence interval [CI] = 34-139) and decreases in IL-6 (RR = -118 mL, 95% CI = -193 to -43) and vascular endothelial growth factor ([VEGF] RR = -178 mL, 95% CI = -314 to -43). CONCLUSIONS Circulating IL-6, VEGF, and FeNO are associated with lung function in adults being treated for TB/HIV. These biomarkers may help identify individuals at higher risk for post-TB lung disease and elucidate targetable pathways to modify the risk of chronic lung impairment among TB survivors.
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Affiliation(s)
- Pholo Maenetje
- The Aurum Institute, Johannesburg, South Africa
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Yeonsoo Baik
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Diana B Schramm
- Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mboyo Di-Tamba Willy Vangu
- Department of Nuclear Medicine, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Caroline T Tiemessen
- Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Yun Li
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hardy Kornfeld
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, USA
| | - Gavin Churchyard
- The Aurum Institute, Johannesburg, South Africa
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Sara C Auld
- Departments of Medicine and Epidemiology, Emory University School of Medicine and Rollins School of Public Health, Atlanta, Georgia, USA
| | - Gregory P Bisson
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Dorvil N, Rivera VR, Riviere C, Berman R, Severe P, Bang H, Lavoile K, Devieux JG, Faustin M, Saintyl G, Mendicuti MD, Pierre S, Apollon A, Dumond E, Forestal GPL, Rouzier V, Marcelin A, McNairy ML, Walsh KF, Dupnik K, Reif LK, Byrne AL, Bousleiman S, Orvis E, Joseph P, Cremieux PY, Pape JW, Koenig SP. Same-day testing with initiation of antiretroviral therapy or tuberculosis treatment versus standard care for persons presenting with tuberculosis symptoms at HIV diagnosis: A randomized open-label trial from Haiti. PLoS Med 2023; 20:e1004246. [PMID: 37294843 PMCID: PMC10292694 DOI: 10.1371/journal.pmed.1004246] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 06/26/2023] [Accepted: 05/25/2023] [Indexed: 06/11/2023] Open
Abstract
BACKGROUND Same-day HIV testing and antiretroviral therapy (ART) initiation is being widely implemented. However, the optimal timing of ART among patients with tuberculosis (TB) symptoms is unknown. We hypothesized that same-day treatment (TB treatment for those diagnosed with TB; ART for those not diagnosed with TB) would be superior to standard care in this population. METHODS AND FINDINGS We conducted an open-label trial among adults with TB symptoms at initial HIV diagnosis at GHESKIO in Haiti; participants were recruited and randomized on the same day. Participants were randomized in a 1:1 ratio to same-day treatment (same-day TB testing with same-day TB treatment if TB diagnosed; same-day ART if TB not diagnosed) versus standard care (initiating TB treatment within 7 days and delaying ART to day 7 if TB not diagnosed). In both groups, ART was initiated 2 weeks after TB treatment. The primary outcome was retention in care with 48-week HIV-1 RNA <200 copies/mL, with intention to treat (ITT) analysis. From November 6, 2017 to January 16, 2020, 500 participants were randomized (250/group); the final study visit occurred on March 1, 2021. Baseline TB was diagnosed in 40 (16.0%) in the standard and 48 (19.2%) in the same-day group; all initiated TB treatment. In the standard group, 245 (98.0%) initiated ART at median of 9 days; 6 (2.4%) died, 15 (6.0%) missed the 48-week visit, and 229 (91.6%) attended the 48-week visit. Among all who were randomized, 220 (88.0%) received 48-week HIV-1 RNA testing; 168 had <200 copies/mL (among randomized: 67.2%; among tested: 76.4%). In the same-day group, 249 (99.6%) initiated ART at median of 0 days; 9 (3.6%) died, 23 (9.2%) missed the 48-week visit, and 218 (87.2%) attended the 48-week visit. Among all who were randomized, 211 (84.4%) received 48-week HIV-1 RNA; 152 had <200 copies/mL (among randomized: 60.8%; among tested: 72.0%). There was no difference between groups in the primary outcome (60.8% versus 67.2%; risk difference: -0.06; 95% CI [-0.15, 0.02]; p = 0.14). Two new grade 3 or 4 events were reported per group; none were judged to be related to the intervention. The main limitation of this study is that it was conducted at a single urban clinic, and the generalizability to other settings is uncertain. CONCLUSIONS In patients with TB symptoms at HIV diagnosis, we found that same-day treatment was not associated with superior retention and viral suppression. In this study, a short delay in ART initiation did not appear to compromise outcomes. TRIAL REGISTRATION This study is registered with ClinicalTrials.gov NCT03154320.
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Affiliation(s)
- Nancy Dorvil
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Vanessa R. Rivera
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Cynthia Riviere
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Richard Berman
- The Analysis Group, Boston, Massachusetts, United States of America
| | - Patrice Severe
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Heejung Bang
- University of California, Davis School of Medicine, Davis, California, United States of America
| | - Kerlyne Lavoile
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Jessy G. Devieux
- Florida International University, Miami, Florida, United States of America
| | - Mikerlyne Faustin
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Giovanni Saintyl
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Maria Duran Mendicuti
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Samuel Pierre
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Alexandra Apollon
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Emelyne Dumond
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | - Vanessa Rouzier
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Weill Cornell Medicine, New York, New York, United States of America
| | - Adias Marcelin
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | - Kathleen F. Walsh
- Weill Cornell Medicine, New York, New York, United States of America
| | - Kathryn Dupnik
- Weill Cornell Medicine, New York, New York, United States of America
| | - Lindsey K. Reif
- Weill Cornell Medicine, New York, New York, United States of America
| | - Anthony L. Byrne
- St. Vincent’s Hospital, Darlinghurst, New South Wales, Australia
| | | | - Eli Orvis
- The Analysis Group, Boston, Massachusetts, United States of America
| | - Patrice Joseph
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | - Jean William Pape
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Weill Cornell Medicine, New York, New York, United States of America
| | - Serena P. Koenig
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
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Baik Y, Maenetje P, Schramm D, Tiemessen C, Ncube I, Churchyard G, Wallis R, Vangu MDT, Kornfeld H, Li Y, Auld SC, Bisson GP. Lung function and collagen 1a levels are associated with changes in 6 min walk test distance during treatment of TB among HIV-infected adults: a prospective cohort study. BMC Pulm Med 2023; 23:53. [PMID: 36737697 PMCID: PMC9896708 DOI: 10.1186/s12890-023-02325-7] [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: 05/17/2022] [Accepted: 01/13/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Patients with tuberculosis (TB) and HIV often present with impairments in lung function and exercise capacity after treatment. We evaluated clinical and immunologic variables associated with a minimum clinically important difference (MCID) in the change in the 6 min walk test distance during the first 24 weeks of antiretroviral (ART) and anti-tubercular therapy. METHODS Adults initiating ART and anti-TB treatment in the setting of newly-diagnosed HIV and pulmonary TB were enrolled in a prospective cohort study in South Africa. Patients underwent 6 min walk tests and spirometry at weeks 0, 4, 12, and 24 and biomarker level measurements early during treatment, at weeks 0, 4, and 12, when inflammation levels are typically elevated. Biomarkers included matrix metalloproteinases-1 (MMP-1), tissue inhibitor of MMP (TIMP)-1, collagen 1a, IL-6, IL-8, vascular cell adhesion molecule 1 (VCAM-1), C-X-C motif chemokine 10 (CXCL-10), CXCL-11, macrophage colony-stimulating factor (M-CSF), plasminogen activator, vascular endothelial growth factor, and chemokine (C-C) motif-2 (CCL-2). An MCID was derived statistically, and achievement of an MCID was modeled as the outcome using logistic regression model. RESULTS Eighty-nine patients walked an average of 393 (± standard deviation = 69) meters at baseline, which increased by an average of 9% (430 ± 70 m) at week 24. The MCID for change in walk distance was estimated as 41 m. Patients experiencing an MCID on treatment had worse lung function, lower 6 min walk test distance, higher levels of proinflammatory biomarkers including TIMP-1 and M-CSF, and lower levels of collagen 1a at baseline. Experiencing an MCID during treatment was associated with increases in forced expiratory volume in 1-s [odds ratio (OR) = 1.17, 95% confidence interval (CI) = 1.05-1.33] and increases in blood collagen 1a levels (OR = 1.31, 95%CI 1.06-1.62). CONCLUSIONS ART and TB treatment are associated with substantial improvements in 6 min walk test distance over time. Achievement of an MCID in the 6 min walk test in this study was associated with more severe disease at baseline and increases in collagen 1a levels and lung function during therapy.
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Affiliation(s)
- Yeonsoo Baik
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, 832 Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104-6021, USA
| | | | - Diana Schramm
- Department of Virology, Faculty of Health Sciences, School of Pathology, University of the Witwatersrand, Johannesburg, South Africa
- Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Caroline Tiemessen
- Department of Virology, Faculty of Health Sciences, School of Pathology, University of the Witwatersrand, Johannesburg, South Africa
- Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Itai Ncube
- The Aurum Institute, Johannesburg, South Africa
| | - Gavin Churchyard
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | | | - Mboyo-di-Tamba Vangu
- Department of Nuclear Medicine, CM Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Hardy Kornfeld
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, USA
| | - Yun Li
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, 832 Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104-6021, USA
| | - Sara C Auld
- Department of Medicine, Emory University Rollins School of Public Health and School of Medicine, Atlanta, GA, USA
| | - Gregory P Bisson
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, 832 Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104-6021, USA.
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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TCA cycle remodeling drives proinflammatory signaling in humans with pulmonary tuberculosis. PLoS Pathog 2021; 17:e1009941. [PMID: 34559866 PMCID: PMC8494353 DOI: 10.1371/journal.ppat.1009941] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 10/06/2021] [Accepted: 09/03/2021] [Indexed: 11/19/2022] Open
Abstract
The metabolic signaling pathways that drive pathologic tissue inflammation and damage in humans with pulmonary tuberculosis (TB) are not well understood. Using combined methods in plasma high-resolution metabolomics, lipidomics and cytokine profiling from a multicohort study of humans with pulmonary TB disease, we discovered that IL-1β-mediated inflammatory signaling was closely associated with TCA cycle remodeling, characterized by accumulation of the proinflammatory metabolite succinate and decreased concentrations of the anti-inflammatory metabolite itaconate. This inflammatory metabolic response was particularly active in persons with multidrug-resistant (MDR)-TB that received at least 2 months of ineffective treatment and was only reversed after 1 year of appropriate anti-TB chemotherapy. Both succinate and IL-1β were significantly associated with proinflammatory lipid signaling, including increases in the products of phospholipase A2, increased arachidonic acid formation, and metabolism of arachidonic acid to proinflammatory eicosanoids. Together, these results indicate that decreased itaconate and accumulation of succinate and other TCA cycle intermediates is associated with IL-1β-mediated proinflammatory eicosanoid signaling in pulmonary TB disease. These findings support host metabolic remodeling as a key driver of pathologic inflammation in human TB disease. Pulmonary tuberculosis (TB) often results in pathologic lung inflammation that causes tissue damage and does not control bacterial replication. This impairs the host response to antibiotic treatment and can result in long term deficits in lung function. Currently, the role of host metabolism in regulating the inflammatory response in TB disease is not well understood. Here, we use detailed immunometabolic phenotyping to show that metabolic remodeling of the tricarboxylic acid (TCA) cycle is closely associated with pathologic inflammatory signaling in humans with TB disease. Accumulation of TCA cycle intermediates in plasma, including the proinflammatory metabolite succinate, as well as decreased concentrations of the anti-inflammatory metabolite itaconate, were associated with increases in IL-1β and upregulation of proinflammatory lipid signaling cascades. This inflammatory network was upregulated following delays in appropriate anti-TB treatment and was associated with prolonged time to sputum culture clearance of Mycobacterium tuberculosis. Our study provides new insights into the metabolic reprograming that leads to pathologic inflammation in humans with pulmonary TB.
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Auld SC, Kornfeld H, Maenetje P, Mlotshwa M, Chase W, Vangu MDT, Torigian DA, Wallis RS, Churchyard G, Bisson GP. Pulmonary restriction predicts long-term pulmonary impairment in people with HIV and tuberculosis. BMC Pulm Med 2021; 21:19. [PMID: 33413293 PMCID: PMC7791797 DOI: 10.1186/s12890-020-01368-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 11/24/2020] [Indexed: 01/26/2023] Open
Abstract
Background While tuberculosis is considered a risk factor for chronic obstructive pulmonary disease, a restrictive pattern of pulmonary impairment may actually be more common among tuberculosis survivors. We aimed to determine the nature of pulmonary impairment before and after treatment among people with HIV and tuberculosis and identify risk factors for long-term impairment.
Methods In this prospective cohort study conducted in South Africa, we enrolled adults newly diagnosed with HIV and tuberculosis who were initiating antiretroviral therapy and tuberculosis treatment. We measured lung function and symptoms at baseline, 6, and 12 months. We compared participants with and without pulmonary impairment and constructed logistic regression models to identify characteristics associated with pulmonary impairment.
Results Among 134 participants with a median CD4 count of 110 cells/μl, 112 (83%) completed baseline spirometry at which time 32 (29%) had restriction, 13 (12%) had obstruction, and 9 (7%) had a mixed pattern. Lung function was dynamic over time and 30 (33%) participants had impaired lung function at 12 months. Baseline restriction was associated with greater symptoms and with long-term pulmonary impairment (adjusted odds ratio 5.44, 95% confidence interval 1.16–25.45), while baseline obstruction was not (adjusted odds ratio 1.95, 95% confidence interval 0.28–13.78).
Conclusions In this cohort of people with HIV and tuberculosis, restriction was the most common, symptomatic, and persistent pattern of pulmonary impairment. These data can help to raise awareness among clinicians about the heterogeneity of post-tuberculosis pulmonary impairment, and highlight the need for further research into mediators of lung injury in this vulnerable population.
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Affiliation(s)
- Sara C Auld
- Departments of Medicine and Epidemiology, School of Medicine and Rollins School of Public Health, Emory University, Atlanta, GA, USA.
| | - Hardy Kornfeld
- Department of Medicine, University of Massachusetts Medical School, Worcester, USA
| | | | | | - William Chase
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Mboyo di-Tamba Vangu
- Department of Nuclear Medicine, CM Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Drew A Torigian
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Gavin Churchyard
- The Aurum Institute, Johannesburg, South Africa.,School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Gregory P Bisson
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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7
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Quinn CM, Poplin V, Kasibante J, Yuquimpo K, Gakuru J, Cresswell FV, Bahr NC. Tuberculosis IRIS: Pathogenesis, Presentation, and Management across the Spectrum of Disease. Life (Basel) 2020; 10:E262. [PMID: 33138069 PMCID: PMC7693460 DOI: 10.3390/life10110262] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/13/2020] [Accepted: 10/21/2020] [Indexed: 12/14/2022] Open
Abstract
Antiretroviral therapy (ART), while essential in combatting tuberculosis (TB) and HIV coinfection, is often complicated by the TB-associated immune reconstitution inflammatory syndrome (TB-IRIS). Depending on the TB disease site and treatment status at ART initiation, this immune-mediated worsening of TB pathology can take the form of paradoxical TB-IRIS, unmasking TB-IRIS, or CNS TB-IRIS. Each form of TB-IRIS has unique implications for diagnosis and treatment. Recently published studies have emphasized the importance of neutrophils and T cell subtypes in TB-IRIS pathogenesis, alongside the recognized role of CD4 T cells and macrophages. Research has also refined our prognostic understanding, revealing how the disease can impact lung function. While corticosteroids remain the only trial-supported therapy for prevention and management of TB-IRIS, increasing interest has been given to biologic therapies directly targeting the immune pathology. TB-IRIS, especially its unmasking form, remains incompletely described and more data is needed to validate biomarkers for diagnosis. Management strategies remain suboptimal, especially in the highly morbid central nervous system (CNS) form of the disease, and further trials are necessary to refine treatment. In this review we will summarize the current understanding of the immunopathogenesis, the presentation of TB-IRIS and the evidence for management recommendations.
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Affiliation(s)
- Carson M. Quinn
- School of Medicine, University of California, San Francisco, CA 94143, USA
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; (J.K.); (J.G.); (F.V.C.)
| | - Victoria Poplin
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, KS 66045, USA; (V.P.); (N.C.B.)
| | - John Kasibante
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; (J.K.); (J.G.); (F.V.C.)
| | - Kyle Yuquimpo
- Department of Medicine, University of Kansas, Kansas City, KS 66045, USA;
| | - Jane Gakuru
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; (J.K.); (J.G.); (F.V.C.)
| | - Fiona V. Cresswell
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; (J.K.); (J.G.); (F.V.C.)
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Medical Research Council, Uganda Virus Research Unit, London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Nathan C. Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, KS 66045, USA; (V.P.); (N.C.B.)
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Stek C, Allwood B, Du Bruyn E, Buyze J, Schutz C, Thienemann F, Lombard A, Wilkinson RJ, Meintjes G, Lynen L. The effect of HIV-associated tuberculosis, tuberculosis-IRIS and prednisone on lung function. Eur Respir J 2020; 55:13993003.01692-2019. [PMID: 31862762 PMCID: PMC7066470 DOI: 10.1183/13993003.01692-2019] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 11/29/2019] [Indexed: 12/26/2022]
Abstract
Residual pulmonary impairment is common after treatment for tuberculosis (TB). Lung function data in patients with HIV-associated TB are scarce, especially in the context of paradoxical TB-associated immune reconstitution inflammatory syndrome (TB-IRIS) and prophylactic prednisone. We aimed to determine the prevalence of lung function abnormalities in patients with HIV-associated TB and CD4 counts ≤100 cells·μL−1 and assess the effect of prophylactic prednisone and the development of paradoxical TB-IRIS on pulmonary impairment. We performed spirometry, 6-min walk test (6MWT) and chest radiography at baseline (week 0) and at weeks 4, 12 and 28 in participants of the PredART trial, which evaluated a 28-day course of prednisone to prevent TB-IRIS in patients with HIV-associated TB commencing antiretroviral therapy. 153 participants underwent spirometry and/or 6MWT at one or more time points. Abnormal spirometry measurements were present in 66% of participants at week 0 and 50% at week 28; low forced vital capacity was the commonest abnormality. Chest radiographs showed little or no abnormalities in the majority of participants. Prednisone use resulted in a 42 m greater 6-min walk distance and a 4.9% higher percentage of predicted forced expiratory volume in 1 s at week 4; these differences were no longer significantly different from week 12 onwards. TB-IRIS did not significantly impair lung function outcome. Residual pulmonary impairment is common in HIV-associated TB. In patients with low CD4 counts, neither prophylactic prednisone as used in our study nor the development of TB-IRIS significantly affected week-28 pulmonary outcome. Post-tuberculosis lung disease is common in patients with HIV-associated TB at high risk of TB-IRIS (CD4 count ≤100 cells·μL−1). Neither TB-IRIS itself, nor prednisone treatment, affected long-term pulmonary outcomes in a South African clinical setting.http://bit.ly/2RjMl9c
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Affiliation(s)
- Cari Stek
- Dept of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium .,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,Dept of Medicine, University of Cape Town, Cape Town, South Africa
| | - Brian Allwood
- Division of Pulmonology, Dept of Medicine, Stellenbosch University, Stellenbosch, South Africa
| | - Elsa Du Bruyn
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,Dept of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jozefien Buyze
- Dept of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Charlotte Schutz
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,Dept of Medicine, University of Cape Town, Cape Town, South Africa
| | - Friedrich Thienemann
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,Dept of Medicine, University of Cape Town, Cape Town, South Africa
| | - Adele Lombard
- Division of Pulmonology, Dept of Medicine, Stellenbosch University, Stellenbosch, South Africa
| | - Robert J Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,Dept of Medicine, University of Cape Town, Cape Town, South Africa.,Dept of Medicine, Imperial College London, London, UK.,The Francis Crick Institute, London, UK
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,Dept of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lutgarde Lynen
- Dept of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
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Antimicrobial Therapy in the Context of the Damage-Response Framework: the Prospect of Optimizing Therapy by Reducing Host Damage. Antimicrob Agents Chemother 2020; 64:AAC.01800-19. [PMID: 31740558 DOI: 10.1128/aac.01800-19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
By design, antimicrobial agents act directly on microbial targets. These drugs aim to eliminate microbes and are remarkably effective against susceptible organisms. Nonetheless, some patients succumb to infectious diseases despite appropriate antimicrobial therapy. Today, with very few exceptions, physicians select antimicrobial therapy based on its activity against the targeted organism without consideration of how the regimen affects patients' immune responses. An important concept to emerge in the past few decades is that immune responses to microbes can be detrimental by enhancing host damage, which can translate into clinical disease. A central tenet of the damage-response framework (DRF) of microbial pathogenesis is that the relevant outcome of host-microbe interaction is the damage that occurs in the host, which can be due to microbial factors, host factors, or both. Given that host damage can make patients sick, reducing it should be a goal of treating infectious diseases. Inflammation and damage that stem from the host response to an infectious disease can increase during therapy with some antimicrobial agents and decrease during therapy with others. When a patient cannot eliminate a microbe with their own immune response, antimicrobial therapy is essential for microbial elimination, and yet it can affect the inflammatory response. In this essay, we discuss antimicrobial therapy in the context of the DRF and propose that consideration of the DRF may help tailor therapy to a patient's need to augment or reduce inflammation.
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