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Jain R, Gupta G, Mitra DK, Guleria R. Diagnosis of extra pulmonary tuberculosis: An update on novel diagnostic approaches. Respir Med 2024; 225:107601. [PMID: 38513873 DOI: 10.1016/j.rmed.2024.107601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 02/29/2024] [Accepted: 03/12/2024] [Indexed: 03/23/2024]
Abstract
Tuberculosis (TB) remains a major global public health problem worldwide. Though Pulmonary TB (PTB) is mostly discussed, one in five cases of TB present are extrapulmonary TB (EPTB) that manifests conspicuous diagnostic and management challenges with respect to the site of infection. The diagnosis of EPTB is often delayed or even missed due to insidious clinical presentation, pauci-bacillary nature of the disease, and lack of laboratory facilities in the resource limited settings. Culture, the classical gold standard for the diagnosis of tuberculosis, suffers from increased technical and logistical constraints in EPTB cases. Other than culture, several other tests are available but their feasibility and effciacy for the detection of EPTB is still the matter of interest. We need more specific and precise test/s for the various forms of EPTB diagnosis which can easily be applied in the routine TB control program is required. A test that can contribute remarkably towards improving EPTB case detection reducing the morbidity and mortality is the utmost requirement. In this review we described the scenario of molecular and other noval methods available for laboratory diagnosis of EPTB, and also discussed the challenges linked with each diagnostic method. This review will make the readers aware of new emerging diagnostic techniques in the field of EPTB diagnosis. They can make an informed decision to choose the appropriate one according to the test availability, their clinical settings and financial considerations.
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Affiliation(s)
- Rashi Jain
- Department of Pulmonary Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, 110029, India; Department of Transplant Immunology and Immunogenetics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Gopika Gupta
- Department of Transplant Immunology and Immunogenetics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - D K Mitra
- Department of Transplant Immunology and Immunogenetics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Randeep Guleria
- Department of Pulmonary Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, 110029, India; Institute of Internal Medicine & Respiratory and Sleep Medicine, Medanta-The Medicity, Gurugram, Haryana, 122033, India.
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Ajantha P, Puri MM, Tayal D, Khalid U. Urinary lipoarabinomannan in individuals with sputum-negative pulmonary tuberculosis. Indian J Med Res 2024; 159:206-212. [PMID: 38577859 PMCID: PMC11050756 DOI: 10.4103/ijmr.ijmr_2074_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND OBJECTIVES Tuberculosis (TB) is a major global cause of ill health. Sputum microscopy for confirmation of presumptive pulmonary TB (PTB) has a reportedly low sensitivity of 22-43 per cent for single smear and up to 60 per cent under optimal conditions. National TB Elimination Programme in India recommends the use of cartridge-based nucleic acid amplification test (CBNAAT) and culture for microbiological confirmation in presumptive PTB individuals with sputum smear negative test. The use of lateral flow urine lipoarabinomannan (LF-LAM) is usually recommended for the diagnosis of TB in HIV-positive individuals with low CD4 counts or those who are seriously ill. The objective of this study was to detect urinary LAM using cage nanotechnology that does not require a physiologic or immunologic consequence of HIV infection for LAM quantification in human urine in 50 HIV-seronegative sputum smear-negative PTB individuals. METHODS To study the diagnostic value of urinary LAM in sputum smear negative PTB individuals, a cage based nanotechnology ELISA technique was used for urinary LAM in three different groups of participants. Fifty smears negative PTB clinically diagnosed, 15 smear positive PTB and 15 post TB sequel individuals. Sputum was tested by smear, CBNAAT, and culture along with urine LAM before treatment. The results were interpreted by ROC curve in comparison to the standard tests like CBNAAT and culture. RESULTS The mean urinary LAM value was 0.84 ng/ml in 37 culture-positive [Mycobacterium tuberculosis (M.tb)] and 0.49 ng/ml in 13 culture-negative (M.tb) smear-negative individuals with PTB, respectively. In 47 smear-negative PTB cases with microbiologically confirmed TB by CBNAAT, the mean urinary LAM was 0.76 ng/ml. The mean urinary LAM in post-TB sequel individuals was 0.47 ng/ml. As per the receiver operating characteristic curve, cut-off value of urinary LAM in individuals with smear-negative PTB microbiologically confirmed by: (i) CBNAAT was 0.695 ng/ml and (ii) culture was 0.615 ng/ml. INTERPRETATION CONCLUSIONS The findings of this study suggest that individuals with smear-negative PTB and a urinary LAM value of >0.615 ng/ml were most likely to have microbiological confirmed TB while those with a LAM value <0.615 ng/ml >0.478 ng/ml are less likely and those with a value <0.478 ng/ml are unlikely to have microbiological confirmed TB.
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Affiliation(s)
- P. Ajantha
- Department of TB and Chest, National Institute of Tuberculosis & Respiratory Diseases, New Delhi, India
| | - Man Mohan Puri
- Department of TB and Chest, National Institute of Tuberculosis & Respiratory Diseases, New Delhi, India
| | - Devika Tayal
- Department of Bio-chemistry, National Institute of Tuberculosis & Respiratory Diseases, New Delhi, India
| | - U. Khalid
- Department of Epidemiology, National Institute of Tuberculosis & Respiratory Diseases, New Delhi, India
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Huang L, Niu Y, Zhang L, Yang R, Wu M. Diagnostic value of chemiluminescence for urinary lipoarabinomannan antigen assay in active tuberculosis: insights from a retrospective study. Front Cell Infect Microbiol 2023; 13:1291974. [PMID: 38145052 PMCID: PMC10748405 DOI: 10.3389/fcimb.2023.1291974] [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: 09/10/2023] [Accepted: 11/09/2023] [Indexed: 12/26/2023] Open
Abstract
Purpose This study aimed to assess the efficacy of chemiluminescence-based urinary lipoarabinomannan (LAM) antigen assay as a diagnostic tool for identifying active tuberculosis. Methods A retrospective study was conducted on 166 Tuberculosis (TB), 22 Non-Tuberculous Mycobacteria (NTM), 69 Non-TB cases, and 73 healthy controls from Zhangjiagang First Peoples Hospital between July 2022 and November 2022. Clinical and laboratory data were collected, including urine samples for LAM antigen detection, sputum samples and pleural effusion for GeneXpert, TB-DNA, and culture. Results TB group exhibited a higher LAM positivity rate (P < 0.001). CD4 count and diabetes as independent factors influencing the diagnostic accuracy of LAM. The LAM assay showed a sensitivity of 50.6% and a specificity of 95.65%. Notably, LAM's sensitivity was superior to TB-DNA (50.60% vs. 38.16%, P < 0.05). LAM's PTB detection rate was 51.7%, superior to TB-DNA (P = 0.047). Moreover, in EPTB cases, the LAM detection rate was 42.11%, surpassing Gene Xpert (P = 0.042), as well as exceeding the detection rates of TB-DNA and sputum culture. Conclusion LAM antigen detection using chemiluminescence has demonstrated outstanding clinical diagnostic value for active TB, especially in the diagnosis of extrapulmonary TB. The convenience of sample collection in this diagnostic approach allows for widespread application in the clinical diagnosis of active tuberculosis, particularly in cases of EPTB and sputum-negative patients.
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Affiliation(s)
- Luyi Huang
- Department of Infectious, Zhangjiagang First Peoples Hospital, Suzhou, China
| | - Yayan Niu
- Department of Tuberculosis, The Fifth People’s Hospital of Suzhou, The Affiliated Infectious Diseases Hospital of Soochow University, Suzhou, China
| | - Li Zhang
- Department of Infectious, Zhangjiagang First Peoples Hospital, Suzhou, China
| | - Rong Yang
- Department of Infectious, Zhangjiagang First Peoples Hospital, Suzhou, China
| | - Meiying Wu
- Department of Tuberculosis, The Fifth People’s Hospital of Suzhou, The Affiliated Infectious Diseases Hospital of Soochow University, Suzhou, China
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Torrelles JB, Chatterjee D. Collected Thoughts on Mycobacterial Lipoarabinomannan, a Cell Envelope Lipoglycan. Pathogens 2023; 12:1281. [PMID: 38003746 PMCID: PMC10675199 DOI: 10.3390/pathogens12111281] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/18/2023] [Accepted: 10/24/2023] [Indexed: 11/26/2023] Open
Abstract
The presence of lipoarabinomannan (LAM) in the Mycobacterium tuberculosis (Mtb) cell envelope was first reported close to 100 years ago. Since then, numerous studies have been dedicated to the isolation, purification, structural definition, and elucidation of the biological properties of Mtb LAM. In this review, we present a brief historical perspective on the discovery of Mtb LAM and the herculean efforts devoted to structurally characterizing the molecule because of its unique structural and biological features. The significance of LAM remains high to this date, mainly due to its distinct immunological properties in conjunction with its role as a biomarker for diagnostic tests due to its identification in urine, and thus can serve as a point-of-care diagnostic test for tuberculosis (TB). In recent decades, LAM has been thoroughly studied and massive amounts of information on this intriguing molecule are now available. In this review, we give the readers a historical perspective and an update on the current knowledge of LAM with information on the inherent carbohydrate composition, which is unique due to the often puzzling sugar residues that are specifically found on LAM. We then guide the readers through the complex and myriad immunological outcomes, which are strictly dependent on LAM's chemical structure. Furthermore, we present issues that remain unresolved and represent the immediate future of LAM research. Addressing the chemistry, functions, and roles of LAM will lead to innovative ways to manipulate the processes that involve this controversial and fascinating biomolecule.
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Affiliation(s)
- Jordi B. Torrelles
- International Center for the Advancement of Research and Education (I • Care), Texas Biomedical Research Institute, San Antonio, TX 78227, USA
- Population Health Program, Texas Biomedical Research Institute, San Antonio, TX 78227, USA
| | - Delphi Chatterjee
- Mycobacteria Research Laboratories, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO 80523, USA
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Singh UB, Angitha KP, Bhatnagar A, Sharma S, Bir R, Singh K, Nabeta P, Ruhwald M, Kabra SK, Lodha R. GeneXpert Ultra in Urine Samples for Diagnosis of Extra-Pulmonary Tuberculosis. Curr Microbiol 2023; 80:361. [PMID: 37796343 DOI: 10.1007/s00284-023-03503-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 09/18/2023] [Indexed: 10/06/2023]
Abstract
Extra-pulmonary tuberculosis (EPTB) continues to be difficult to diagnose. Novel biomarkers in biological specimens offer promise. Detection of Mycobacterium tuberculosis (Mtb) DNA in urine could prove useful in diagnosis of EPTB, possibly due to disseminated disease or micro-abscesses reported in kidneys. The current study was designed to detect Mtb DNA in stored urine samples from patients with EPTB. Diagnosis of EPTB was reached using Microbiological Reference Standards (MRS) on samples from the disease site using WHO Recommended Diagnostics (WRD), [smear microscopy, liquid culture (MGIT-960)] and GX (molecular WRD, mWRD) and Comprehensive reference standards [CRS, clinical presentation, microbiological reference standards, radiology, histopathology]. GX-Ultra was performed on urine samples stored in -80oC deep freezer, retrospectively. Of 70 patients, 51 (72.9%) were classified as confirmed TB, 11 (15.7%) unconfirmed TB, and 8 (11.4%) unlikely TB. GX-Ultra in urine samples demonstrated sensitivity of 52.9% and specificity of 57.9% against MRS, and higher sensitivity of 56.5% and specificity of 100% against CRS. The sensitivity and specificity of GX-Ultra in urine was 53.6% and 75% for pus sample subset and 52.2% and 53.3% for fluid sample subset. Urine being non-invasive and easy to collect, detection of Mtb DNA using mWRD in urine samples is promising for diagnosis of EPTB.
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Affiliation(s)
- Urvashi B Singh
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India.
| | - K P Angitha
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Anuj Bhatnagar
- Department of Tuberculosis and Chest Diseases, Rajan Babu Institute for Pulmonary Medicine and Tuberculosis, New Delhi, India
| | - Sangeeta Sharma
- Department of Pediatrics, National Institute of Tuberculosis and Respiratory Diseases, New Delhi, India
| | - Raunak Bir
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Kiran Singh
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Pamela Nabeta
- The global alliance for diagnostics, FIND, Geneva, Switzerland
| | - Morten Ruhwald
- The global alliance for diagnostics, FIND, Geneva, Switzerland
| | - Sushil K Kabra
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Lodha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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Dahiya B, Mehta N, Soni A, Mehta PK. Diagnosis of extrapulmonary tuberculosis by GeneXpert MTB/RIF Ultra assay. Expert Rev Mol Diagn 2023; 23:561-582. [PMID: 37318829 DOI: 10.1080/14737159.2023.2223980] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/06/2023] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Diagnosis of extrapulmonary tuberculosis (EPTB) is an arduous task owing to different anatomical locations, unusual clinical presentations, and sparse bacillary load in clinical specimens. Although GeneXpert® MTB/RIF is a windfall in TB diagnostics including EPTB, it yields low sensitivities but high specificities in many EPTB specimens. To further improve the sensitivity of GeneXpert®, GeneXpert® Ultra, a fully nested real-time PCR targeting IS6110, IS1081 and rpoB (Rv0664) has been endorsed by the WHO (2017), wherein melt curve analysis is utilized to detect rifampicin-resistance (RIF-R). AREA COVERED We described the assay chemistry/work design of Xpert Ultra and evaluated its performance in several EPTB types, that is, TB lymphadenitis, TB pleuritis, TB meningitis, and so on, against the microbiological reference standard or composite reference standard. Notably, Xpert Ultra exhibited better sensitivities than Xpert, but mostly at the compensation of specificity values. Moreover, Xpert Ultra exhibited low false-negative and false-positive RIF-R results, compared with Xpert. We also detailed other molecular tests, that is, Truenat MTBTM/TruPlus, commercial real-time PCR, line probe assay, and so on, for EPTB diagnosis. EXPERT OPINION A combination of clinical features, imaging, histopathological findings, and Xpert Ultra are adequate for definite EPTB diagnosis so as to initiate an early anti-tubercular therapy.
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Affiliation(s)
- Bhawna Dahiya
- Centre for Biotechnology, Maharshi Dayanand University, Rohtak, India
| | - Neeru Mehta
- Department of Medical Electronics, Ambedkar Delhi Skill & Entrepreneurship University, Shakarpur, New Delhi, India
| | - Aishwarya Soni
- Centre for Biotechnology, Maharshi Dayanand University, Rohtak, India
- Department of Biotechnology, Deenbandhu Chhotu Ram University of Science and Technology, Murthal, Sonipat, India
| | - Promod K Mehta
- Centre for Biotechnology, Maharshi Dayanand University, Rohtak, India
- Microbiology Department, Faculty of Allied Health Sciences, SGT University, Budhera, Gurgaon, India
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Cummings MJ, Bakamutumaho B, Jain K, Price A, Owor N, Kayiwa J, Namulondo J, Byaruhanga T, Muwanga M, Nsereko C, Nayiga I, Kyebambe S, Che X, Sameroff S, Tokarz R, Wong W, Postler TS, Larsen MH, Lipkin WI, Lutwama JJ, O’Donnell MR. Brief Report: Detection of Urine Lipoarabinomannan Is Associated With Proinflammatory Innate Immune Activation, Impaired Host Defense, and Organ Dysfunction in Adults With Severe HIV-Associated Tuberculosis in Uganda. J Acquir Immune Defic Syndr 2023; 93:79-85. [PMID: 36701194 PMCID: PMC10079575 DOI: 10.1097/qai.0000000000003159] [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] [Indexed: 01/27/2023]
Abstract
BACKGROUND The immunopathology of disseminated HIV-associated tuberculosis (HIV/TB), a leading cause of critical illness and death among persons living with HIV in sub-Saharan Africa, is incompletely understood. Reflective of hematogenously disseminated TB, detection of lipoarabinomannan (LAM) in urine is associated with greater bacillary burden and poor outcomes in adults with HIV/TB. METHODS We determined the relationship between detection of urine TB-LAM, organ dysfunction, and host immune responses in a prospective cohort of adults hospitalized with severe HIV/TB in Uganda. Generalized additive models were used to analyze the association between urine TB-LAM grade and concentrations of 14 soluble immune mediators. Whole-blood RNA-sequencing data were used to compare transcriptional profiles between patients with high- vs. low-grade TB-LAM results. RESULTS Among 157 hospitalized persons living with HIV, 40 (25.5%) had positive urine TB-LAM testing. Higher TB-LAM grade was associated with more severe physiologic derangement, organ dysfunction, and shock. Adjusted generalized additive models showed that higher TB-LAM grade was significantly associated with higher concentrations of mediators reflecting proinflammatory innate and T-cell activation and chemotaxis (IL-8, MIF, MIP-1β/CCL4, and sIL-2Ra/sCD25). Transcriptionally, patients with higher TB-LAM grades demonstrated multifaceted impairment of antibacterial defense including reduced expression of genes encoding cytotoxic and autophagy-related proteins and impaired cross-talk between innate and cell-mediated immune effectors. CONCLUSIONS Our findings add to emerging data suggesting pathobiological relationships between LAM, TB dissemination, innate cell activation, and evasion of host immunity in severe HIV/TB. Further translational studies are needed to elucidate the role for immunomodulatory therapies, in addition to optimized anti-TB treatment, in this often critically ill population.
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Affiliation(s)
- Matthew J. Cummings
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Barnabas Bakamutumaho
- Department of Arbovirology, Emerging and Re-emerging Infectious Diseases, Uganda Virus Research Institute, Entebbe, Uganda
- Immunizable Diseases Unit, Uganda Virus Research Institute, Entebbe, Uganda
| | - Komal Jain
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Adam Price
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Nicholas Owor
- Department of Arbovirology, Emerging and Re-emerging Infectious Diseases, Uganda Virus Research Institute, Entebbe, Uganda
| | - John Kayiwa
- Department of Arbovirology, Emerging and Re-emerging Infectious Diseases, Uganda Virus Research Institute, Entebbe, Uganda
| | - Joyce Namulondo
- Department of Arbovirology, Emerging and Re-emerging Infectious Diseases, Uganda Virus Research Institute, Entebbe, Uganda
| | - Timothy Byaruhanga
- Department of Arbovirology, Emerging and Re-emerging Infectious Diseases, Uganda Virus Research Institute, Entebbe, Uganda
| | - Moses Muwanga
- Entebbe General Referral Hospital, Ministry of Health, Entebbe, Uganda
| | | | - Irene Nayiga
- Entebbe General Referral Hospital, Ministry of Health, Entebbe, Uganda
| | - Stephen Kyebambe
- Entebbe General Referral Hospital, Ministry of Health, Entebbe, Uganda
| | - Xiaoyu Che
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY, USA
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Stephen Sameroff
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Rafal Tokarz
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Wai Wong
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Thomas S. Postler
- Department of Microbiology and Immunology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Michelle H. Larsen
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - W. Ian Lipkin
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY, USA
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Julius J. Lutwama
- Department of Arbovirology, Emerging and Re-emerging Infectious Diseases, Uganda Virus Research Institute, Entebbe, Uganda
| | - Max R. O’Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
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Davuluri KS, Singh AK, Singh AV, Chaudhary P, Raman SK, Kushwaha S, Singh SV, Chauhan DS. Atorvastatin Potentially Reduces Mycobacterial Severity through Its Action on Lipoarabinomannan and Drug Permeability in Granulomas. Microbiol Spectr 2023; 11:e0319722. [PMID: 36719189 PMCID: PMC10100658 DOI: 10.1128/spectrum.03197-22] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 11/05/2022] [Indexed: 02/01/2023] Open
Abstract
The majority of preclinical research has shown that Mycobacterium tuberculosis can modify host lipids in various ways. To boost its intramacrophage survival, M. tuberculosis causes host lipids to build up, resulting in the development of lipid-laden foam cells. M. tuberculosis binds to and enters the macrophage via the cell membrane cholesterol. Aggregation of cholesterol in the cell wall of M. tuberculosis and an increase in vascularity at the granuloma site reduce the permeability of rifampicin and isoniazid concentrations. However, very few studies have assessed the effect of statins on drug penetration. Here, we used atorvastatin, a 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor, to observe its effect on the bacterial burden by increasing the drug concentration at the infection site. We looked into how atorvastatin could be used in conjunction with first-line drugs to promote drug permeation. In this study, we detected an accumulation of drugs at the peripheral sites of the lungs and impaired drug distribution to the diseased sites. The efficacy of antituberculosis drugs, with atorvastatin as an adjunct, on the viability of M. tuberculosis cells was demonstrated. A nontoxic statin dosage established phenotypic and normal granuloma vasculature and showed an additive effect with rifampicin and isoniazid. Our data show that statins help to reduce the tuberculosis bacterial burden. Our findings reveal that the bacterial load is connected with impaired drug permeability resulting from lipid accumulation in the bacterial cell wall. Statin therapy combined with antituberculosis medications have the potential to improve treatment in tuberculosis patients. IMPORTANCE Mycobacterium tuberculosis binds to and enters the macrophage via the cell membrane cholesterol. M. tuberculosis limits phagosomal maturation and activation without engaging in phagocytosis. Aggregation of cholesterol in the cell wall of M. tuberculosis and an increase in the vascularity at the granuloma site reduce the permeability of rifampicin and isoniazid concentrations. However, very few studies have assessed the effect of statins on drug penetration, which can be increased through a reduction in cholesterol and vascularity. Herein, we used atorvastatin, a 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor, to observe its effect on bacterial burden through increasing the drug concentration at the infection site. Our main research goal is to diminish mycobacterial dissemination and attenuate bacterial growth by increasing drug permeability.
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Affiliation(s)
- Kusuma Sai Davuluri
- Department of Microbiology and Molecular Biology, ICMR, National JALMA Institute for Leprosy and Other Mycobacterial Diseases, Tajganj, Agra, India
| | - Amit Kumar Singh
- Department of Microbiology and Molecular Biology, ICMR, National JALMA Institute for Leprosy and Other Mycobacterial Diseases, Tajganj, Agra, India
| | - Ajay Vir Singh
- Department of Microbiology and Molecular Biology, ICMR, National JALMA Institute for Leprosy and Other Mycobacterial Diseases, Tajganj, Agra, India
| | - Pooja Chaudhary
- Department of Microbiology and Molecular Biology, ICMR, National JALMA Institute for Leprosy and Other Mycobacterial Diseases, Tajganj, Agra, India
| | - Sunil Kumar Raman
- Division of Pharmaceutics and Pharmacokinetics, CSIR, Central Drug Research Institute, Lucknow, India
| | - Shweta Kushwaha
- Department of Microbiology and Molecular Biology, ICMR, National JALMA Institute for Leprosy and Other Mycobacterial Diseases, Tajganj, Agra, India
| | | | - Devendra Singh Chauhan
- Department of Microbiology and Molecular Biology, ICMR, National JALMA Institute for Leprosy and Other Mycobacterial Diseases, Tajganj, Agra, India
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Lyu M, Zhou Y, Chen Y, Lai H, Wang Y, Cheng Y, Li J, Peng W, Liu T, Jiang X, Li M, Zhao Z, Ying B. Exploring the eligibility of all reported lipoarabinomannan-testing assays in different clinical situations: a systematic review and meta-analysis of 97 articles. Int J Infect Dis 2022; 125:19-34. [PMID: 36244601 DOI: 10.1016/j.ijid.2022.10.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 09/17/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES How to choose proper lipoarabinomannan-testing assays for diagnosing tuberculosis (TB) in different populations baffles clinicians. This work assessed all reported lipoarabinomannan assays' performance and aimed to identify the eligibility of each assay and offer guidance for clinicians. METHODS We searched PubMed, Embase, and Web of Science until August 23, 2020. The risk of bias was evaluated by QADAS-2. Heterogeneity was evaluated by the Cochran Q test and I2. Sensitivity and specificity were pooled by a bivariate mixed model (register number: CRD42021270506). RESULTS A total of 97 articles, covering 144 trials, 16 assays, 45,679 participants, and eight sample types, were divided into five groups. Electrochemiluminescence (ECL) had a sensitivity of 65%, specificity of 92%, and an area under curve (AUC) of 0.85 in diagnosing pulmonary TB in adults. ECL showed a promising diagnostic ability (sensitivity: 78%; specificity: 88%; AUC: 0.88) in patients with HIV, especially for urine detection (sensitivity: 90%; specificity: 89%; AUC: 0.95). The enzyme-linked immune assay showed a preference for diagnosing TB in Asians and Africans, especially in Africans who were smear-positive (sensitivity: 80%; specificity: 88%; AUC: 0.91). CONCLUSION ECL was recommended for diagnosing pulmonary TB in adults, especially for TB/HIV co-infection. Taking urine as a sample further enhanced ECL's diagnostic performance. Enzyme-linked immune assay was recommended as an additional TB-related detection for smear-positive Africans.
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Affiliation(s)
- Mengyuan Lyu
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, 610044, China; West China School of Medicine, Sichuan University, Chengdu, 610044, China
| | - Yanbing Zhou
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, 610044, China; West China School of Medicine, Sichuan University, Chengdu, 610044, China
| | - Yi Chen
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, 610044, China; West China School of Medicine, Sichuan University, Chengdu, 610044, China
| | - Hongli Lai
- West China School of Medicine, Sichuan University, Chengdu, 610044, China
| | - Yili Wang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, 610044, China; West China School of Medicine, Sichuan University, Chengdu, 610044, China
| | - Yuhui Cheng
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, 610044, China; West China School of Medicine, Sichuan University, Chengdu, 610044, China
| | - Jing Li
- Department of Laboratory Medicine, PanZhihua Central Hospital, PanZhihua, 617067, China
| | - Wu Peng
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, 610044, China; West China School of Medicine, Sichuan University, Chengdu, 610044, China
| | - Tangyuheng Liu
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, 610044, China; West China School of Medicine, Sichuan University, Chengdu, 610044, China
| | - Xin Jiang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, 610044, China; West China School of Medicine, Sichuan University, Chengdu, 610044, China
| | - Mei Li
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, 610044, China; West China School of Medicine, Sichuan University, Chengdu, 610044, China
| | - Zhenzhen Zhao
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, 610044, China; West China School of Medicine, Sichuan University, Chengdu, 610044, China
| | - Binwu Ying
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, 610044, China; West China School of Medicine, Sichuan University, Chengdu, 610044, China.
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Ketema W, Woubishet K, Tesfaye S, Gutema S, Taye K, Shibeshi MS, Tagesse N. A Breakthrough in the Challenges of Tuberculosis Diagnosis: Lateral Flow Urine Lipoarabinomannan (LAM) Assay for the Diagnosis of Active Tuberculosis in a Subset of Human Immuno Deficiency Virus (HIV) Patients at Hawassa University Comprehensive Specialized Hospital, Hawassa, Ethiopia. Int Med Case Rep J 2022; 15:393-397. [PMID: 35942080 PMCID: PMC9356588 DOI: 10.2147/imcrj.s373197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 07/27/2022] [Indexed: 11/26/2022] Open
Abstract
Background Tuberculosis is commonly detected late or not at all in HIV-positive people. Rapid and sensitive molecular tests like Gene X-pert have recently become available to replace or supplement existing conventional tests for detecting tuberculosis, and the World Health Organization (WHO) recommends that these rapid techniques be used as the initial diagnostic test for tuberculosis to avoid delays in starting appropriate treatment. The lipoarabinomannan was approved by the national ministry of health in August 2021 for the detection of active tuberculosis in specified groups. Case Summary It is not uncommon for tuberculosis to be difficult to diagnose in this population, and we believe that our experiences with urine lipoarabinomannan for the detection of active tuberculosis will benefit other clinicians and, ultimately, patients. We discussed the experiences of two human immunodeficiency virus (HIV) patients with putative active tuberculosis, whose tuberculosis workups were negative by conventional methods, including gene expert but found to be positive by urine lipoarabinomannan and who were started on anti-tuberculosis medicines and improved. They are now in a good condition and are taking their medications regularly without any problems. Conclusion Ending the suffering of HIV patients necessitates lobbying for more accurate tuberculosis diagnosis. The urine Lipoarabinomannan (LAM) assay will address the shortcomings of traditional sputum-based diagnostic tests including sputum Acid Fast Bacilli (AFB) and Gene X-pert, making it a credible alternative for diagnosing tuberculosis in people with HIV. The results of this case series demonstrated that TB LAM is a milestone for the difficulties in TB diagnosis in HIV patients. As of now, the national guideline only suggests urine LAM for HIV patients who fulfill the set criteria. We recommend the stakeholders to increase the availability, and extrapolate the recommendation to other populations including non-HIV patients.
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Affiliation(s)
- Worku Ketema
- Department of Pediatrics and Child Health, College of Health Sciences, Hawassa University, Hawassa, Sidama, Ethiopia
- Correspondence: Worku Ketema, Email
| | - Kindie Woubishet
- Department of Internal Medicine, College of Health Sciences, Hawassa University, Hawassa, Sidama, Ethiopia
| | - Sisay Tesfaye
- Department of Internal Medicine, College of Health Sciences, Hawassa University, Hawassa, Sidama, Ethiopia
| | - Selamawit Gutema
- Department of Internal Medicine, College of Health Sciences, Hawassa University, Hawassa, Sidama, Ethiopia
| | - Kefyalew Taye
- Department of Pediatrics and Child Health, College of Health Sciences, Hawassa University, Hawassa, Sidama, Ethiopia
| | - Mulugeta Sitot Shibeshi
- Department of Pediatrics and Child Health, College of Health Sciences, Hawassa University, Hawassa, Sidama, Ethiopia
| | - Negash Tagesse
- Department of Pediatrics and Child Health, College of Health Sciences, Hawassa University, Hawassa, Sidama, Ethiopia
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Yusoof KA, García JI, Schami A, Garcia-Vilanova A, Kelley HV, Wang SH, Rendon A, Restrepo BI, Yotebieng M, Torrelles JB. Tuberculosis Phenotypic and Genotypic Drug Susceptibility Testing and Immunodiagnostics: A Review. Front Immunol 2022; 13:870768. [PMID: 35874762 PMCID: PMC9301132 DOI: 10.3389/fimmu.2022.870768] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 06/06/2022] [Indexed: 12/24/2022] Open
Abstract
Tuberculosis (TB), considered an ancient disease, is still killing one person every 21 seconds. Diagnosis of Mycobacterium tuberculosis (M.tb) still has many challenges, especially in low and middle-income countries with high burden disease rates. Over the last two decades, the amount of drug-resistant (DR)-TB cases has been increasing, from mono-resistant (mainly for isoniazid or rifampicin resistance) to extremely drug resistant TB. DR-TB is problematic to diagnose and treat, and thus, needs more resources to manage it. Together with+ TB clinical symptoms, phenotypic and genotypic diagnosis of TB includes a series of tests that can be used on different specimens to determine if a person has TB, as well as if the M.tb strain+ causing the disease is drug susceptible or resistant. Here, we review and discuss advantages and disadvantages of phenotypic vs. genotypic drug susceptibility testing for DR-TB, advances in TB immunodiagnostics, and propose a call to improve deployable and low-cost TB diagnostic tests to control the DR-TB burden, especially in light of the increase of the global burden of bacterial antimicrobial resistance, and the potentially long term impact of the coronavirus disease 2019 (COVID-19) disruption on TB programs.
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Affiliation(s)
- Kizil A. Yusoof
- Graduate School of Biomedical Sciences, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Juan Ignacio García
- Population Health Program, Tuberculosis Group, Texas Biomedical Research Institute, San Antonio, TX, United States
- *Correspondence: Juan Ignacio García, ; Blanca I. Restrepo, ; Marcel Yotebieng, ; Jordi B. Torrelles,
| | - Alyssa Schami
- Graduate School of Biomedical Sciences, University of Texas Health San Antonio, San Antonio, TX, United States
- Population Health Program, Tuberculosis Group, Texas Biomedical Research Institute, San Antonio, TX, United States
| | - Andreu Garcia-Vilanova
- Population Health Program, Tuberculosis Group, Texas Biomedical Research Institute, San Antonio, TX, United States
| | - Holden V. Kelley
- Population Health Program, Tuberculosis Group, Texas Biomedical Research Institute, San Antonio, TX, United States
| | - Shu-Hua Wang
- Department of Internal Medicine, Division of Infectious Diseases, College of Medicine and Global One Health Initiative, The Ohio State University, Columbus, OH, United States
| | - Adrian Rendon
- Centro de Investigación, Prevención y Tratamiento de Infecciones Respiratorias (CIPTIR), Hospital Universitario de Monterrey Universidad Autónoma de Nuevo León (UANL), Monterrey, Mexico
| | - Blanca I. Restrepo
- School of Public Health, University of Texas Health Science Center at Houston, Brownsville, TX, United States
- School of Medicine, South Texas Diabetes and Obesity Institute, University of Texas Rio Grande Valley, Edinburg, TX, United States
- *Correspondence: Juan Ignacio García, ; Blanca I. Restrepo, ; Marcel Yotebieng, ; Jordi B. Torrelles,
| | - Marcel Yotebieng
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, New York City, NY, United States
- *Correspondence: Juan Ignacio García, ; Blanca I. Restrepo, ; Marcel Yotebieng, ; Jordi B. Torrelles,
| | - Jordi B. Torrelles
- Graduate School of Biomedical Sciences, University of Texas Health San Antonio, San Antonio, TX, United States
- Population Health Program, Tuberculosis Group, Texas Biomedical Research Institute, San Antonio, TX, United States
- *Correspondence: Juan Ignacio García, ; Blanca I. Restrepo, ; Marcel Yotebieng, ; Jordi B. Torrelles,
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12
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Wake RM, Govender NP, Omar SV, Ismail F, Tiemessen CT, Harrison TS, Jarvis JN. Rapid urine-based screening tests increase the yield of same-day tuberculosis diagnoses among patients living with advanced HIV disease. AIDS 2022; 36:839-844. [PMID: 35075041 DOI: 10.1097/qad.0000000000003177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Investigation of the diagnostic yield of urine-based tuberculosis (TB) screening in patients with advanced HIV disease. DESIGN A cross-sectional screening study. SETTING HIV outpatient clinics and wards at two hospitals in Johannesburg, South Africa, between June 2015 and October 2017. PARTICIPANTS Two hundred and one patients living with advanced HIV disease (CD4+ T-lymphocytes <100 cells/μl) attending healthcare facilities following cryptococcal antigen (CrAg) screening. INTERVENTION Screening for TB using sputum for microscopy, culture, and Xpert MTB/Rif and urine for lipoarabinomannan (LAM) and Xpert Ultra. MAIN OUTCOME MEASURES Proportion of positive results using each testing modality, sensitivity, and specificity of urine-based testing compared with culture, and survival outcomes during 6 months follow up. RESULTS Urine was obtained from 177 of 181 (98%) participants and sputum from 91 (50%). Urine-based screening increased same-day diagnostic yield from 7 (4%) to 31 (17%). A positive urine test with either LAM or Xpert Ultra had 100% sensitivity (95% confidence interval, 59-100%) for detecting culture-positive TB at any site. Patients with newly diagnosed TB on urine-based screening were initiated on treatment and did not have excess mortality compared with the remainder of the cohort. CONCLUSION Urine is an easily obtainable sample with utility for detecting TB in patients with advanced HIV disease. Combining urine and sputum-based screening in this population facilitates additional same-day TB diagnoses and early treatment initiation, potentially reducing the risk of TB-related mortality. Urine-based as well as sputum-based screening for TB should be integrated with CrAg screening in patients living with advanced HIV disease.
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Affiliation(s)
- Rachel M Wake
- Institute for Infection and Immunity, St George's University of London
- Clinical Academic Group in Infection and Immunity, St George's University Hospital NHS Foundation Trust, London, UK
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses (CHARM), National Institute for Communicable Diseases, a Division of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
| | - Nelesh P Govender
- Institute for Infection and Immunity, St George's University of London
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses (CHARM), National Institute for Communicable Diseases, a Division of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
- MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
- Faculty of Health Sciences, University of the Witwatersrand, Witwatersrand
- Division of Medical Microbiology, University of Cape Town, Cape Town
| | - Shaheed V Omar
- Faculty of Health Sciences, University of the Witwatersrand, Witwatersrand
- Department of Medical Microbiology, University of Pretoria, Pretoria
- Centre for Tuberculosis
| | - Farzana Ismail
- Department of Medical Microbiology, University of Pretoria, Pretoria
- Centre for Tuberculosis
| | - Caroline T Tiemessen
- Faculty of Health Sciences, University of the Witwatersrand, Witwatersrand
- Centre for HIV & STIs, National Institute for Communicable Diseases, a Division of the NHLS, Johannesburg, South Africa
| | - Thomas S Harrison
- Institute for Infection and Immunity, St George's University of London
- Clinical Academic Group in Infection and Immunity, St George's University Hospital NHS Foundation Trust, London, UK
- MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Botswana Harvard AIDS Institute Partnership, Gabarone, Botswana
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13
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Nel J, Gupta-Wright A. Urine tuberculosis diagnostics in patients with advanced HIV. AIDS 2022; 36:897-898. [PMID: 35506266 DOI: 10.1097/qad.0000000000003178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Jeremy Nel
- University of the Witwatersrand, Johannesburg, South Africa
| | - Ankur Gupta-Wright
- Institute for Global Health, University College London
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London UK
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Vaezipour N, Fritschi N, Brasier N, Bélard S, Domínguez J, Tebruegge M, Portevin D, Ritz N. Towards Accurate Point-of-Care Tests for Tuberculosis in Children. Pathogens 2022; 11:pathogens11030327. [PMID: 35335651 PMCID: PMC8949489 DOI: 10.3390/pathogens11030327] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 12/20/2022] Open
Abstract
In childhood tuberculosis (TB), with an estimated 69% of missed cases in children under 5 years of age, the case detection gap is larger than in other age groups, mainly due to its paucibacillary nature and children’s difficulties in delivering sputum specimens. Accurate and accessible point-of-care tests (POCTs) are needed to detect TB disease in children and, in turn, reduce TB-related morbidity and mortality in this vulnerable population. In recent years, several POCTs for TB have been developed. These include new tools to improve the detection of TB in respiratory and gastric samples, such as molecular detection of Mycobacterium tuberculosis using loop-mediated isothermal amplification (LAMP) and portable polymerase chain reaction (PCR)-based GeneXpert. In addition, the urine-based detection of lipoarabinomannan (LAM), as well as imaging modalities through point-of-care ultrasonography (POCUS), are currently the POCTs in use. Further to this, artificial intelligence-based interpretation of ultrasound imaging and radiography is now integrated into computer-aided detection products. In the future, portable radiography may become more widely available, and robotics-supported ultrasound imaging is currently being trialed. Finally, novel blood-based tests evaluating the immune response using “omic-“techniques are underway. This approach, including transcriptomics, metabolomic, proteomics, lipidomics and genomics, is still distant from being translated into POCT formats, but the digital development may rapidly enhance innovation in this field. Despite these significant advances, TB-POCT development and implementation remains challenged by the lack of standard ways to access non-sputum-based samples, the need to differentiate TB infection from disease and to gain acceptance for novel testing strategies specific to the conditions and settings of use.
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Affiliation(s)
- Nina Vaezipour
- Mycobacterial and Migrant Health Research Group, University Children’s Hospital Basel, Department for Clinical Research, University of Basel, 4056 Basel, Switzerland; (N.V.); (N.F.)
- Infectious Disease and Vaccinology Unit, University Children’s Hospital Basel, University of Basel, 4056 Basel, Switzerland
| | - Nora Fritschi
- Mycobacterial and Migrant Health Research Group, University Children’s Hospital Basel, Department for Clinical Research, University of Basel, 4056 Basel, Switzerland; (N.V.); (N.F.)
| | - Noé Brasier
- Department of Health Sciences and Technology, Institute for Translational Medicine, ETH Zurich, 8093 Zurich, Switzerland;
- Department of Digitalization & ICT, University Hospital Basel, 4031 Basel, Switzerland
| | - Sabine Bélard
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité–Universitätsmedizin Berlin, 13353 Berlin, Germany;
- Institute of Tropical Medicine and International Health, Charité–Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - José Domínguez
- Institute for Health Science Research Germans Trias i Pujol. CIBER Enfermedades Respiratorias, Universitat Autònoma de Barcelona, 08916 Barcelona, Spain;
| | - Marc Tebruegge
- Department of Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, University College London, London WCN1 1EH, UK;
- Department of Pediatrics, The Royal Children’s Hospital Melbourne, The University of Melbourne, Parkville, VIC 3052, Australia
| | - Damien Portevin
- Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, 4123 Allschwil, Switzerland;
- University of Basel, 4001 Basel, Switzerland
| | - Nicole Ritz
- Mycobacterial and Migrant Health Research Group, University Children’s Hospital Basel, Department for Clinical Research, University of Basel, 4056 Basel, Switzerland; (N.V.); (N.F.)
- Department of Pediatrics, The Royal Children’s Hospital Melbourne, The University of Melbourne, Parkville, VIC 3052, Australia
- Department of Paediatrics and Paediatric Infectious Diseases, Children’s Hospital, Lucerne Cantonal Hospital, 6000 Lucerne, Switzerland
- Correspondence: ; Tel.: +41-61-704-1212
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15
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Cummings MJ, Bakamutumaho B, Price A, Owor N, Kayiwa J, Namulondo J, Byaruhanga T, Muwanga M, Nsereko C, Sameroff S, Tokarz R, Wong W, Shah SS, Larsen MH, Lipkin WI, Lutwama JJ, O’Donnell MR. Multidimensional analysis of the host response reveals prognostic and pathogen-driven immune subtypes among adults with sepsis in Uganda. Crit Care 2022; 26:36. [PMID: 35130948 PMCID: PMC8822787 DOI: 10.1186/s13054-022-03907-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 01/26/2022] [Indexed: 12/24/2022] Open
Abstract
Background The global burden of sepsis is concentrated in sub-Saharan Africa, where severe infections disproportionately affect young, HIV-infected adults and high-burden pathogens are unique. In this context, poor understanding of sepsis immunopathology represents a crucial barrier to development of locally-effective treatment strategies. We sought to determine inter-individual immunologic heterogeneity among adults hospitalized with sepsis in a sub-Saharan African setting, and characterize associations between immune subtypes, infecting pathogens, and clinical outcomes. Methods Among a prospective observational cohort of 288 adults hospitalized with suspected sepsis in Uganda, we applied machine learning methods to 14 soluble host immune mediators, reflective of key domains of sepsis immunopathology (innate and adaptive immune activation, endothelial dysfunction, fibrinolysis), to identify immune subtypes in randomly-split discovery (N = 201) and internal validation (N = 87) sub-cohorts. In parallel, we applied similar methods to whole-blood RNA-sequencing data from a consecutive subset of patients (N = 128) to identify transcriptional subtypes, which we characterized using biological pathway and immune cell-type deconvolution analyses. Results Unsupervised clustering consistently identified two immune subtypes defined by differential activation of pro-inflammatory innate and adaptive immune pathways, with transcriptional evidence of concomitant CD56(-)/CD16( +) NK-cell expansion, T-cell exhaustion, and oxidative-stress and hypoxia-induced metabolic and cell-cycle reprogramming in the hyperinflammatory subtype. Immune subtypes defined by greater pro-inflammatory immune activation, T-cell exhaustion, and metabolic reprogramming were consistently associated with a high-prevalence of severe and often disseminated HIV-associated tuberculosis, as well as more extensive organ dysfunction, worse functional outcomes, and higher 30-day mortality. Conclusions Our results highlight unique host- and pathogen-driven features of sepsis immunopathology in sub-Saharan Africa, including the importance of severe HIV-associated tuberculosis, and reinforce the need to develop more biologically-informed treatment strategies in the region, particularly those incorporating immunomodulation. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03907-3.
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16
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Simieneh A, Tadesse M, Kebede W, Gashaw M, Abebe G. Combination of Xpert® MTB/RIF and DetermineTM TB-LAM Ag improves the diagnosis of extrapulmonary tuberculosis at Jimma University Medical Center, Oromia, Ethiopia. PLoS One 2022; 17:e0263172. [PMID: 35113917 PMCID: PMC8812938 DOI: 10.1371/journal.pone.0263172] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 01/14/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Ethiopia is one of the high burden countries for extrapulmonary tuberculosis (EPTB); however, the prompt diagnosis of EPTB remains challenging. This study is aimed to evaluate the diagnostic performance of Xpert MTB/RIF and DetermineTM TB-LAM Ag (TB-LAM) for the prompt diagnosis of EPTB in Ethiopia. METHODS A total of 147 presumptive EPTB patients, including 23 HIV- positive participants were enrolled. Extra-pulmonary samples were collected from all presumptive EPTB cases and tested for Mycobacterium tuberculosis complex (MTBC) using fluorescent microscopy, Xpert MTB/RIF, and culture. Additionally, urine samples were also collected from 126 participants and were tested by DetermineTM TB-LAM Ag (Alere Inc, Waltham, USA). The Sensitivity and specificity of Xpert and TB- LAM tests were calculated by comparing with a composite reference standard (CRS), which comprises smear microscopy, culture and response to empirical anti-TB treatment. RESULTS Of 147 patients, 23 (15.6%) were confirmed EPTB cases (culture-positive), 14 (9.5%) were probable EPTB (clinically, radiologically or cytologically positive and received anti-TB treatment with good response), and 110 (74.8%) were classified as "non- TB" cases. Compared to the composite reference standard (CRS), the overall sensitivity and specificity of Xpert MTB/RIF were 43.2% and 100%, respectively with the highest sensitivity for Lymph node aspirate (85.7%) and lower sensitivity for pleural fluid (14.3%) and 100% specificity for all specimen types. The sensitivity and specificity of TB-LAM were 33.3% and 94.4% respectively with the highest sensitivity for HIV co-infected participants (83.3%). The sensitivity of the combination of Xpert MTB/RIF and TB-LAM tests regardless of HIV status was 61.1% whereas the sensitivity was improved to 83.3% for HIV-positive cases. CONCLUSION TB-LAM alone has low sensitivity for EPTB diagnosis; however, the combination of TB-LAM and Xpert MTB/RIF improves the diagnosis of EPTB particularly for countries with high EPTB and HIV cases.
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Affiliation(s)
- Asnake Simieneh
- Mycobacteriology Research Center, Jimma University, Jimma, Ethiopia
- School of Medical Laboratory Sciences, Faculty of Health Sciences, Jimma University, Jimma, Ethiopia
- Department of Medical Laboratory Sciences, Mizan-Tepi University, Mizan, Ethiopia
| | - Mulualem Tadesse
- Mycobacteriology Research Center, Jimma University, Jimma, Ethiopia
- School of Medical Laboratory Sciences, Faculty of Health Sciences, Jimma University, Jimma, Ethiopia
| | - Wakjira Kebede
- Mycobacteriology Research Center, Jimma University, Jimma, Ethiopia
- School of Medical Laboratory Sciences, Faculty of Health Sciences, Jimma University, Jimma, Ethiopia
| | - Mulatu Gashaw
- School of Medical Laboratory Sciences, Faculty of Health Sciences, Jimma University, Jimma, Ethiopia
| | - Gemeda Abebe
- Mycobacteriology Research Center, Jimma University, Jimma, Ethiopia
- School of Medical Laboratory Sciences, Faculty of Health Sciences, Jimma University, Jimma, Ethiopia
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17
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Panraksa Y, Amin AG, Graham B, Henry CS, Chatterjee D. Immobilization of Proteinase K for urine pretreatment to improve diagnostic accuracy of active tuberculosis. PLoS One 2021; 16:e0257615. [PMID: 34547058 PMCID: PMC8454978 DOI: 10.1371/journal.pone.0257615] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 09/05/2021] [Indexed: 11/19/2022] Open
Abstract
The World Health Organization (WHO) calls for the development of a rapid, biomarker-based, non-sputum test capable of detecting all forms of tuberculosis (TB) at the point-of-care to enable immediate treatment initiation. Lipoarabinomannan (LAM) is the only WHO-endorsed TB biomarker that can be detected in urine, an easily collected sample matrix. For obtaining optimal sensitivity, we and others have shown that some form of sample pretreatment is necessary to remove background from patient urine samples. A number of systems are paper-based often destined for resource limited settings. Our current work presents incorporation of one such sample pretreatment, proteinase K (ProK) immobilized on paper (IPK) and test its performance in comparison to standard proteinase K (SPK) treatment that involves addition and deactivation at high temperature prior to performing a capture ELISA. Herein, a simple and economical method was developed for using ProK immobilized strips to pretreat urine samples. Simplification and cost reduction of the proposed pretreatment strip were achieved by using Whatman no.1 paper and by minimizing the concentration of ProK (an expensive but necessary reagent) used to pretreat the clinical samples prior to ELISA. To test the applicability of IPK, capture ELISA was carried out on either LAM-spiked urine or the clinical samples after pretreatment with ProK at 400 μg/mL for 30 minutes at room temperature. The optimal conditions and stability of the IPK were tested and validation was performed on a set of 25 previously analyzed archived clinical urine samples with known TB and HIV status. The results of IPK and SPK treated samples were in agreement showing that the urine LAM test currently under development has the potential to reach adult and pediatric patients regardless of HIV status or site of infection, and to facilitate global TB control to improve assay performance and ultimately treatment outcomes.
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Affiliation(s)
- Yosita Panraksa
- Mycobacteria Research Laboratories, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO, United States of America
| | - Anita G. Amin
- Mycobacteria Research Laboratories, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO, United States of America
| | - Barbara Graham
- Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO, United States of America
| | - Charles S. Henry
- Department of Chemistry, Colorado State University, Fort Collins, CO, United States of America
- School of Biomedical Engineering, Colorado State University, Fort Collins, CO, United States of America
| | - Delphi Chatterjee
- Mycobacteria Research Laboratories, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO, United States of America
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Nathavitharana RR, Lederer P, Chaplin M, Bjerrum S, Steingart KR, Shah M. Impact of diagnostic strategies for tuberculosis using lateral flow urine lipoarabinomannan assay in people living with HIV. Cochrane Database Syst Rev 2021; 8:CD014641. [PMID: 34416013 PMCID: PMC8407503 DOI: 10.1002/14651858.cd014641] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Tuberculosis is the primary cause of hospital admission in people living with HIV, and the likelihood of death in the hospital is unacceptably high. The Alere Determine TB LAM Ag test (AlereLAM) is a point-of-care test and the only lateral flow lipoarabinomannan assay (LF-LAM) assay currently commercially available and recommended by the World Health Organization (WHO). A 2019 Cochrane Review summarised the diagnostic accuracy of LF-LAM for tuberculosis in people living with HIV. This systematic review assesses the impact of the use of LF-LAM (AlereLAM) on mortality and other patient-important outcomes. OBJECTIVES To assess the impact of the use of LF-LAM (AlereLAM) on mortality in adults living with HIV in inpatient and outpatient settings. To assess the impact of the use of LF-LAM (AlereLAM) on other patient-important outcomes in adults living with HIV, including time to diagnosis of tuberculosis, and time to initiation of tuberculosis treatment. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE (PubMed); Embase (Ovid); Science Citation Index Expanded (Web of Science), BIOSIS Previews, Scopus, LILACS; ProQuest Dissertations and Theses; ClinicalTrials.gov; and the WHO ICTRP up to 12 March 2021. SELECTION CRITERIA Randomized controlled trials that compared a diagnostic intervention including LF-LAM with diagnostic strategies that used smear microscopy, mycobacterial culture, a nucleic acid amplification test such as Xpert MTB/RIF, or a combination of these tests. We included adults (≥ 15 years) living with HIV. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for eligibility, extracted data, and analysed risk of bias using the Cochrane tool for assessing risk of bias in randomized studies. We contacted study authors for clarification as needed. We used risk ratio (RR) with 95% confidence intervals (CI). We used a fixed-effect model except in the presence of clinical or statistical heterogeneity, in which case we used a random-effects model. We assessed the certainty of the evidence using GRADE. MAIN RESULTS We included three trials, two in inpatient settings and one in outpatient settings. All trials were conducted in sub-Saharan Africa and assessed the impact of diagnostic strategies that included LF-LAM on mortality when the test was used in conjunction with other tuberculosis diagnostic tests or clinical assessment for clinical decision-making in adults living with HIV. Inpatient settings In inpatient settings, the use of LF-LAM testing as part of a tuberculosis diagnostic strategy likely reduces mortality in people living with HIV at eight weeks compared to routine tuberculosis diagnostic testing without LF-LAM (pooled RR 0.85, 95% CI 0.76 to 0.94; 5102 participants, 2 trials; moderate-certainty evidence). That is, people living with HIV who received LF-LAM had 15% lower risk of mortality. The absolute effect was 34 fewer deaths per 1000 (from 14 fewer to 55 fewer). In inpatient settings, the use of LF-LAM testing as part of a tuberculosis diagnostic strategy probably results in a slight increase in the proportion of people living with HIV who were started on tuberculosis treatment compared to routine tuberculosis diagnostic testing without LF-LAM (pooled RR 1.26, 95% CI 0.94 to 1.69; 5102 participants, 2 trials; moderate-certainty evidence). Outpatient settings In outpatient settings, the use of LF-LAM testing as part of a tuberculosis diagnostic strategy may reduce mortality in people living with HIV at six months compared to routine tuberculosis diagnostic testing without LF-LAM (RR 0.89, 95% CI 0.71 to 1.11; 2972 participants, 1 trial; low-certainty evidence). Although this trial did not detect a difference in mortality, the direction of effect was towards a mortality reduction, and the effect size was similar to that in inpatient settings. In outpatient settings, the use of LF-LAM testing as part of a tuberculosis diagnostic strategy may result in a large increase in the proportion of people living with HIV who were started on tuberculosis treatment compared to routine tuberculosis diagnostic testing without LF-LAM (RR 5.44, 95% CI 4.70 to 6.29, 3022 participants, 1 trial; low-certainty evidence). Other patient-important outcomes Assessment of other patient-important and implementation outcomes in the trials varied. The included trials demonstrated that a higher proportion of people living with HIV were able to produce urine compared to sputum for tuberculosis diagnostic testing; a higher proportion of people living with HIV were diagnosed with tuberculosis in the group that received LF-LAM; and the incremental diagnostic yield was higher for LF-LAM than for urine or sputum Xpert MTB/RIF. AUTHORS' CONCLUSIONS In inpatient settings, the use of LF-LAM as part of a tuberculosis diagnostic testing strategy likely reduces mortality and probably results in a slight increase in tuberculosis treatment initiation in people living with HIV. The reduction in mortality may be due to earlier diagnosis, which facilitates prompt treatment initiation. In outpatient settings, the use of LF-LAM testing as part of a tuberculosis diagnostic strategy may reduce mortality and may result in a large increase in tuberculosis treatment initiation in people living with HIV. Our results support the implementation of LF-LAM to be used in conjunction with other WHO-recommended tuberculosis diagnostic tests to assist in the rapid diagnosis of tuberculosis in people living with HIV.
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Affiliation(s)
- Ruvandhi R Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Philip Lederer
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts, USA
| | - Marty Chaplin
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Stephanie Bjerrum
- Department of Clinical Research, Research Unit of Infectious Diseases, University of Southern Denmark, Odense, Denmark
| | - Karen R Steingart
- Honorary Research Fellow, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Maunank Shah
- Department of Medicine, Division of Infectious Diseases, John Hopkins University School of Medicine, Baltimore, Maryland, USA
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Chernick L, Kalla IS, Venter M. Clinical, radiological, and laboratory predictors of a positive urine lipoarabinomannan test in sputum-scarce and sputum-negative patients with HIV-associated tuberculosis in two Johannesburg hospitals. South Afr J HIV Med 2021; 22:1234. [PMID: 34394971 PMCID: PMC8335785 DOI: 10.4102/sajhivmed.v22i1.1234] [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: 02/19/2021] [Accepted: 04/30/2021] [Indexed: 11/24/2022] Open
Abstract
Background Tuberculosis (TB) is a major cause of mortality in persons living with HIV (PLWH). Sputum-based diagnosis of TB in patients with low CD4 counts is hampered by paucibacillary disease and consequent sputum scarcity or negative sputum results. Urine lipoarabinomannan (LAM) has shown promise in the point-of-care detection of TB in this patient subset but lacks sensitivity, and its exact role in a diagnostic algorithm for TB in South Africa remains to be clarified. Objectives The objective of this study was to better define the patient profile and the TB characteristics associated with a positive urine LAM (LAM+ve) test. Method This multicentre retrospective record review examined the clinical, radiological, and laboratory characteristics of hospitalised PLWH receiving urine LAM testing with sputum-scarce and/or negative sputum GeneXpert ® (mycobacterium tuberculosis/resistance to rifampicin [MTB/RIF]) results. Results More than a third of patients, 121/342 (35%), were LAM+ve. The positive yield was greater in the sputum-scarce than the sputum-negative group, 66/156 (42%) versus 55/186 (30%), P = 0.0141, respectively. Patients who were LAM+ve were more likely to be confused (odds ratio [OR] = 2.2, 95% confidence interval [CI] = 1.2–3.7, P = 0.0045), have a higher median heart rate (P = 0.0135) and an elevated quick sepsis-related organ failure assessment score (≥ 2), OR = 3.5, 95% CI = 1.6–7.6, P = 0.0014. A LAM+ve test was significantly associated with disseminated TB (dTB), P < 0.0001, TB-related immune reconstitution inflammatory syndrome (IRIS), P = 0.0035, and abdominal TB, P < 0.0001. Laboratory predictors of a LAM+ve status included renal dysfunction, P = 0.044, severe anaemia, P = 0.0116, and an elevated C-reactive protein, P = 0.0131. Of the 12 PLWH with disseminated non-TB mycobacteria cultured from the blood and/or bone marrow, n = 9 (75%) had a LAM+ve result (OR = 5.8, 95% CI = 1.6–20.8, P = 0.0053). Conclusion Urine LAM testing of hospitalised PLWH with suspected active TB had significant diagnostic utility in those that were sputum-scarce or sputum-negative. A LAM+ve result was associated with dTB, clinical and laboratory markers of severe illness, and TB-IRIS. Disseminated non-tuberculous mycobacterial infection of hospitalised PLWH may also yield urine LAM+ve results, and mycobacterial cultures must be checked in those non-responsive to conventional TB treatment. Selective use of the LAM test in the critically ill is likely to maximise the diagnostic yield, improve the test’s predictive value, and reduce the time to TB diagnosis and initiation of treatment.
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Affiliation(s)
- Lior Chernick
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Ismail S Kalla
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Division of Pulmonology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Michelle Venter
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Division of Infectious Diseases, Department of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa
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Comella-del-Barrio P, Bimba JS, Adelakun R, Kontogianni K, Molina-Moya B, Osazuwa O, Creswell J, Cuevas LE, Domínguez J. Fujifilm SILVAMP TB-LAM for the Diagnosis of Tuberculosis in Nigerian Adults. J Clin Med 2021; 10:2514. [PMID: 34204120 PMCID: PMC8201264 DOI: 10.3390/jcm10112514] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/26/2021] [Accepted: 06/04/2021] [Indexed: 01/14/2023] Open
Abstract
There is a need for diagnostics for tuberculosis (TB) that are easy to use, able to screen non-sputum samples, and able to provide rapid results for the management of both immunocompromised and immunocompetent individuals. The Fujifilm SILVAMP TB LAM (FujiLAM) assay, a new non-sputum based point of need test for the diagnosis of TB, could potentially address most of these needs. We evaluated the performance of FujiLAM in HIV positive and HIV negative patients with presumptive TB attending three district hospitals in Nigeria. Consecutive patients were asked to provide urine samples on the spot, which were tested with FujiLAM. The results were compared against a positive culture and/or Xpert MTB/RIF as the reference standard. Forty-five patients had bacteriologically confirmed TB, and 159 had negative culture and Xpert MTB/RIF (no TB). The FujiLAM test was positive in 23 (sensitivity 65.7%, 95% CI = 48-80) HIV negative and seven (70%, 95% CI = 35-92) HIV positive patients with bacteriological confirmation of TB. FujiLAM was negative in 97 (specificity 99.0%, 95% CI = 94-100) HIV negative and 56 (93.3%, 95% CI = 83-98) HIV positive patients without TB. The FujiLAM test has good diagnostic accuracy for considering its application in both HIV positive and HIV negative patients with TB.
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Affiliation(s)
- Patricia Comella-del-Barrio
- Institut d’Investigació Germans Trias i Pujol, CIBER Enfermedades Respiratorias (CIBERES), Universitat Autònoma de Barcelona, Carretera del Canyet, Camí de les Escoles s/n, Badalona, 08916 Barcelona, Spain; (P.C.-d.-B.); (B.M.-M.)
| | - John S. Bimba
- Zankli Research Centre and Department of Community Medicine, Bingham University, Karu 961105, Nigeria; (J.S.B.); (O.O.); (L.E.C.)
| | - Ramota Adelakun
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK; (R.A.); (K.K.)
| | - Konstantina Kontogianni
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK; (R.A.); (K.K.)
| | - Bárbara Molina-Moya
- Institut d’Investigació Germans Trias i Pujol, CIBER Enfermedades Respiratorias (CIBERES), Universitat Autònoma de Barcelona, Carretera del Canyet, Camí de les Escoles s/n, Badalona, 08916 Barcelona, Spain; (P.C.-d.-B.); (B.M.-M.)
| | - Okoedoh Osazuwa
- Zankli Research Centre and Department of Community Medicine, Bingham University, Karu 961105, Nigeria; (J.S.B.); (O.O.); (L.E.C.)
| | - Jacob Creswell
- Stop TB Partnership, TB REACH, 1218 Geneva, Switzerland;
| | - Luis E. Cuevas
- Zankli Research Centre and Department of Community Medicine, Bingham University, Karu 961105, Nigeria; (J.S.B.); (O.O.); (L.E.C.)
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK; (R.A.); (K.K.)
| | - José Domínguez
- Institut d’Investigació Germans Trias i Pujol, CIBER Enfermedades Respiratorias (CIBERES), Universitat Autònoma de Barcelona, Carretera del Canyet, Camí de les Escoles s/n, Badalona, 08916 Barcelona, Spain; (P.C.-d.-B.); (B.M.-M.)
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21
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Diagnostic Performance of the Fujifilm SILVAMP TB-LAM in Children with Presumptive Tuberculosis. J Clin Med 2021; 10:jcm10091914. [PMID: 33925008 PMCID: PMC8124322 DOI: 10.3390/jcm10091914] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/17/2021] [Accepted: 04/23/2021] [Indexed: 11/16/2022] Open
Abstract
Current diagnostics for tuberculosis (TB) only manage to confirm a small proportion of children with TB and require respiratory samples, which are difficult to obtain. There is a need for non-invasive biomarker-based tests as an alternative to sputum testing. Fujifilm SILVAMP TB lipoarabinomannan (FujiLAM), a lateral-flow test to detect lipoarabinomannan in urine, is a novel non-sputum-based point-of-care diagnostic reported to have increased sensitivity for the diagnosis of TB among human immunodeficiency virus (HIV)-infected adults. We evaluate the performance of FujiLAM in children with presumptive TB. Fifty-nine children attending a paediatric hospital in Haiti with compatible signs and symptoms of TB were examined using Xpert MTB/RIF, smear microscopy and X-rays, and classified according to the certainty of diagnosis into bacteriologically confirmed TB (n = 5), unconfirmed TB (bacteriologically negative, n = 50) and unlikely TB (n = 4). Healthy children (n = 20) were enrolled as controls. FujiLAM sensitivity and specificity were 60% and 95% among children with confirmed TB. FujiLAM's high specificity and its characteristics as a point-of-care indicate the test has a good potential for the diagnosis of TB in children.
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22
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The utility of point-of-care urinary lipoarabinomannan testing for the diagnosis of tuberculosis in critically ill patients: a prospective observational study. BMC Infect Dis 2021; 21:281. [PMID: 33740905 PMCID: PMC7980562 DOI: 10.1186/s12879-021-05979-y] [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: 11/30/2020] [Accepted: 03/09/2021] [Indexed: 11/10/2022] Open
Abstract
Background Tuberculosis is a major global public health concern. Patients with tuberculosis who require critical care have a high mortality and delay in initiating antituberculous therapy is associated with increased mortality. Lipoarabinomannan (LAM) is a lipopolysaccharide found in the cell wall of Mycobacterium tuberculosis. Urinary LAM may be used as a bedside diagnostic test for tuberculosis. Methods The study was a single centre, prospective observational study that compared the utility of urinary LAM with conventional tuberculosis diagnostic modalities in patients with suspected tuberculosis who required intensive care admission. Urinary LAM testing was performed using the Alere Determine TB LAM Ag lateral flow assay test strips. A patient was classified as having confirmed tuberculosis if they met the following criteria: a clinical presentation compatible with tuberculosis, with either a positive TB culture, a positive GeneXpert, or a histological diagnosis of tuberculosis. Results Fifty patients were included in the study, with 12 having confirmed tuberculosis. All patients received mechanical ventilation, and the ICU mortality was 60%. Urinary LAM had a sensitivity of 50.0% (95% CI, 21.1 to 78.9%) and a specificity of 84.2% (95% CI, 68.8 to 94.0%) for confirmed tuberculosis. Conclusion Urinary LAM allows for rapid bedside diagnosis of tuberculosis in critically ill patients. A positive urinary LAM should prompt consideration to initiate antituberculous treatment while the results of further diagnostic testing are awaited.
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23
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Amin AG, De P, Graham B, Calderon RI, Franke MF, Chatterjee D. Urine lipoarabinomannan in HIV uninfected, smear negative, symptomatic TB patients: effective sample pretreatment for a sensitive immunoassay and mass spectrometry. Sci Rep 2021; 11:2922. [PMID: 33536495 PMCID: PMC7859189 DOI: 10.1038/s41598-021-82445-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 01/20/2021] [Indexed: 12/12/2022] Open
Abstract
Our study sought to determine whether urine lipoarabinomannan (LAM) could be validated in a sample cohort that consisted mainly of HIV uninfected individuals that presented with tuberculosis symptoms. We evaluated two tests developed in our laboratory, and used them on clinical samples from Lima, Peru where incidence of HIV is low. ELISA analysis was performed on 160 samples (from 140 adult culture-confirmed TB cases and 20 symptomatic TB-negative child controls) using 100 μL of urine after pretreatment with Proteinase K. Two different mouse monoclonal antibodies-CS35 and CHCS9-08 were used individually for capture of urine LAM. Among cases, optical density (OD450) values had a positive association with higher bacillary loads. The 20 controls had negative values (below the limit of detection). The assay correctly identified all samples (97-100% accuracy confidence interval). For an alternate validation of the ELISA results, we analyzed all 160 urine samples using an antibody independent chemoanalytical approach. Samples were called positive only when LAM surrogates-tuberculostearic acid (TBSA) and D-arabinose (D-ara)-were found to be present in similar amounts. All TB cases, including the 40 with a negative sputum smear had LAM in detectable quantities in urine. None of the controls had detectable amounts of LAM. Our study shows that urinary LAM detection is feasible in HIV uninfected, smear negative TB patients.
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Affiliation(s)
- Anita G Amin
- Mycobacteria Research Laboratory, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO, 80523, USA
| | - Prithwiraj De
- Mycobacteria Research Laboratory, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO, 80523, USA
| | - Barbara Graham
- Mycobacteria Research Laboratory, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO, 80523, USA
| | - Roger I Calderon
- Socios en Salud Sucursal Peru, Lima, 15001, Peru
- Programa Academico de Tuberculose, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, 21941-590, Brazil
| | - Molly F Franke
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, 02115, USA
| | - Delphi Chatterjee
- Mycobacteria Research Laboratory, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO, 80523, USA.
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Bose P, Harit AK, Das R, Sau S, Iyer AK, Kashaw SK. Tuberculosis: current scenario, drug targets, and future prospects. Med Chem Res 2021. [DOI: 10.1007/s00044-020-02691-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Gupta-Wright A, Fielding K, Wilson D, van Oosterhout JJ, Grint D, Mwandumba HC, Alufandika-Moyo M, Peters JA, Chiume L, Lawn SD, Corbett EL. Tuberculosis in Hospitalized Patients With Human Immunodeficiency Virus: Clinical Characteristics, Mortality, and Implications From the Rapid Urine-based Screening for Tuberculosis to Reduce AIDS Related Mortality in Hospitalized Patients in Africa. Clin Infect Dis 2020; 71:2618-2626. [PMID: 31781758 PMCID: PMC7744971 DOI: 10.1093/cid/ciz1133] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 11/15/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) is the major killer of people living with human immunodeficiency virus (HIV) globally, with suboptimal diagnostics and management contributing to high case-fatality rates. METHODS A prospective cohort of patients with confirmed TB (Xpert MTB/RIF and/or Determine TB-LAM Ag positive) identified through screening HIV-positive inpatients with sputum and urine diagnostics in Malawi and South Africa (Rapid urine-based Screening for Tuberculosis to reduce AIDS Related Mortality in hospitalized Patients in Africa [STAMP] trial). Urine was tested prospectively (intervention) or retrospectively (standard of care arm). We defined baseline clinical phenotypes using hierarchical cluster analysis, and also used Cox regression analysis to identify associations with early mortality (≤56 days). RESULTS Of 322 patients with TB confirmed between October 2015 and September 2018, 78.0% had ≥1 positive urine test. Antiretroviral therapy (ART) coverage was 80.2% among those not newly diagnosed, but with median CD4 count 75 cells/µL and high HIV viral loads. Early mortality was 30.7% (99/322), despite near-universal prompt TB treatment. Older age, male sex, ART before admission, poor nutritional status, lower hemoglobin, and positive urine tests (TB-LAM and/or Xpert MTB/RIF) were associated with increased mortality in multivariate analyses. Cluster analysis (on baseline variables) defined 4 patient subgroups with early mortality ranging from 9.8% to 52.5%. Although unadjusted mortality was 9.3% lower in South Africa than Malawi, in adjusted models mortality was similar in both countries (hazard ratio, 0.9; P = .729). CONCLUSIONS Mortality following prompt inpatient diagnosis of HIV-associated TB remained unacceptably high, even in South Africa. Intensified management strategies are urgently needed, for which prognostic indicators could potentially guide both development and subsequent use.
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Affiliation(s)
- Ankur Gupta-Wright
- Tuberculosis Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Katherine Fielding
- Tuberculosis Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
- University of the Witwatersrand, Johannesburg, South Africa
| | - Douglas Wilson
- Department of Medicine, Edendale Hospital, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Joep J van Oosterhout
- Dignitas International, Zomba, Malawi
- Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Daniel Grint
- Tuberculosis Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Henry C Mwandumba
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | | | - Jurgens A Peters
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Lingstone Chiume
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Stephen D Lawn
- Tuberculosis Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Elizabeth L Corbett
- Tuberculosis Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
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García JI, Meléndez J, Álvarez R, Mejía-Chew C, Kelley HV, Sidiki S, Castillo A, Mazariegos C, López-Téllez C, Forno D, Ayala N, Balada-Llasat JM, Mejía-Villatoro CR, Wang SH, Torrelles JB, Ikeda J. Accuracy of the tuberculosis point-of-care Alere determine lipoarabinomannan antigen diagnostic test using α-mannosidase treated and untreated urine in a cohort of people living with HIV in Guatemala. AIDS Res Ther 2020; 17:62. [PMID: 33076996 PMCID: PMC7570414 DOI: 10.1186/s12981-020-00318-8] [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: 02/28/2020] [Accepted: 09/21/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Improved point-of-care diagnostic tests for tuberculosis (TB) in severe immune suppressed people living with HIV (PLWH) are needed to decrease morbidity and mortality outcomes. The aim of the study is to evaluate the performance of the lipoarabinomannan antigen test (LAM-test) with and without α-mannosidase pre-treated urine in a cohort of PLWH in primary care clinics in Guatemala. We further determined TB incidence, and mortality rates and its risk factors in PLWH with TB symptoms. METHODS Prospective longitudinal study of PLWH with TB symptoms. Urine samples were collected at 2 HIV sites to test the sensitivity of the LAM-test in urine with and without α-mannosidase pre-treatment. A composite reference standard of either a positive Mycobacterium tuberculosis complex culture and/or GeneXpert® MTB/RIF (Xpert, Cepheid, Sunnyvale, CA, USA) results was used in the LAM-test diagnostic accuracy studies. Cox proportional hazards regression was used to study mortality predictors. RESULTS The overall sensitivity of the LAM-test was of 56.1% with 95% CI of (43.3-68.3). There were no differences in the LAM-test sensitivity neither by hospital nor by CD4 T cell values. LAM-test sensitivity in PLWH with < 200 CD4 T cells/µl was of 62.2% (95% CI 46.5-76.2). There were no significant differences in sensitivity when comparing LAM-test results obtained from untreated vs. α-mannosidase treated urine [55.2% (95% CI 42.6-67.4) vs. 56.9% (95% CI 44-69.2), respectively]. TB incidence in our cohort was of 21.4/100 person years (PYs) (95% CI 16.6-27.6), and mortality rate was of 11.1/100 PYs (95% CI 8.2-15.0). Importantly, PLWH with a positive LAM-test result had an adjusted hazard ratio (aHR) of death of 1.98 (1.0-3.8) with a significant p value of 0.044 when compared to PLWH with a negative LAM-test result. CONCLUSIONS In this study, α-mannosidase treatment of urine did not significantly increase the LAM-test performance, however; this needs to be further evaluated in a large-scale study due to our study limitations. Importantly, high rates of TB incidence and mortality were found, and a positive LAM-test result predicted mortality in PLWH with TB clinical symptoms.
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Kerkhoff AD, Longley N, Kelly N, Cross A, Vogt M, Wood R, Hermans S, Lawn SD, Harrison TS. Determine TB-LAM point-of-care tuberculosis assay predicts poor outcomes in outpatients during their first year of antiretroviral therapy in South Africa. BMC Infect Dis 2020; 20:555. [PMID: 32736601 PMCID: PMC7393716 DOI: 10.1186/s12879-020-05227-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 07/03/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Determine TB-LAM is the first point-of-care test (POC) for HIV-associated tuberculosis (TB) and rapidly identifies TB in those at high-risk for short-term mortality. While the relationship between urine-LAM and mortality has been previously described, the outcomes of those undergoing urine-LAM testing have largely been assessed during short follow-up periods within diagnostic accuracy studies. We therefore sought to assess the relationship between baseline urine-LAM results and subsequent hospitalization and mortality under real-world conditions among outpatients in the first year of ART. METHODS Consecutive, HIV-positive adults with a CD4 count < 100 cells/uL presenting for ART initiation were enrolled. TB diagnoses and outcomes (hospitalization, loss-to-follow and mortality) were recorded during the first year following enrolment. Baseline urine samples were retrospectively tested using the urine-LAM POC assay. Kaplan Meier survival curves were used to assess the cumulative probability of hospitalization or mortality in the first year of follow-up, according to urine-LAM status. Cox regression analyses were performed to determine independent predictors of hospitalization and mortality at three months and one year of follow-up. RESULTS 468 patients with a median CD4 count of 59 cells/uL were enrolled. There were 140 patients (29.9%) with newly diagnosed TB in the first year of follow-up of which 79 (56.4%) were microbiologically-confirmed. A total of 18% (n = 84) required hospital admission and 12.2% (n = 57) died within a year of study entry. 38 out of 468 (8.1%) patients retrospectively tested urine-LAM positive - including 19.0% of those with microbiologically-proven TB diagnoses (n = 15/79) and 23.0% (n = 14/61) of those with clinical-only TB diagnoses; 9 of 38 (23.7%) of patients retrospectively testing LAM positive were never diagnosed with TB under routine program conditions. Among all patients (n = 468) in the first year of follow-up, a positive urine-LAM result was strongly associated with all-cause hospitalization and mortality with a corresponding adjusted hazard ratio (aHR) of 3.7 (95%CI, 1.9-7.1) and 2.6 (95%, 1.2-5.7), respectively. CONCLUSIONS Systematic urine-LAM testing among ART-naïve HIV-positive outpatients with CD4 counts < 100 cells/uL detected TB cases that were missed under routine programme conditions and was highly predictive for subsequent hospitalization and mortality in the first year of ART.
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Affiliation(s)
- Andrew D. Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California USA
| | - Nicky Longley
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Institute of Infection and Immunity, St George’s University of London, London, UK
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Nicola Kelly
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Anna Cross
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Monica Vogt
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Robin Wood
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Sabine Hermans
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Global Health, Academic Medical Centre, Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, The Netherlands
| | - Stephen D. Lawn
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Thomas S. Harrison
- Institute of Infection and Immunity, St George’s University of London, London, UK
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M D, Bandaru R, Janakiraman V, Sai VVR. A plasmonic fiberoptic absorbance biosensor for mannose-capped lipoarabinomannan based tuberculosis diagnosis. Biosens Bioelectron 2020; 167:112488. [PMID: 32805509 DOI: 10.1016/j.bios.2020.112488] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/16/2020] [Accepted: 07/30/2020] [Indexed: 02/06/2023]
Abstract
Tuberculosis (TB) is a resurgent infectious disease affecting a large number of people in the developing countries. An on-site, affordable diagnostic screening at an early-stage for an immediate anti-TB treatment is known to tremendously minimize the high mortality rates. Lipoarabinomannan (LAM), a surface glycolipid, has been identified as a potential TB biomarker present in urine at ultra-low concentrations of a few fg/mL. Here, we report a plasmonic fiber optic absorbance biosensor (P-FAB) strategy for mannosylated LAM (Man-LAM or Mtb LAM) detection down to attomolar concentrations. It involves a plasmonic sandwich immunoassay on a U-bent fiber optic probe with gold plasmonic (AuNP) labels functionalized with anti-Mtb LAM immunoglobulin M (IgM) and anti-Mtb LAM IgG respectively. The Mtb LAM is quantified in terms of absorption of light passing through the fiber probe using a green LED and a photodetector. The choice of fiber optic probes (fused silica versus polymer), the optimum size (20, 40, 60 and 80 nm) and concentration (2 × , 10 × , and 20 × ) of AuNP labels were investigated to obtain high sensitivity and lower limits of analyte detection (LoD). P-FAB with a simple LED-photodetector pair, 200 μm fused silica U-bent fiber probe and 60 nm (20 × ) AuNP labels gave LoDs down to 1 fg/mL and 10 fg/mL in the buffer and synthetic urine respectively. Moreover, the anti-Mtb LAM IgM bound sensor probes and the AuNP reagent stored at 4 °C were stable up to 45 days. P-FAB based Mtb LAM sensor demonstrates its potential for an on-site TB diagnosis.
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Affiliation(s)
- Divagar M
- Department of Biotechnology, Indian Institute of Technology Madras, Chennai, 600036, India; Biomedical Engineering Division, Department of Applied Mechanics, Indian Institute of Technology Madras, Chennai, 600036, India
| | - Ramakrishna Bandaru
- Biomedical Engineering Division, Department of Applied Mechanics, Indian Institute of Technology Madras, Chennai, 600036, India; Current Affiliation: SRM Institute of Science and Technology, Tankular, Chennai, 603203, India
| | - Vani Janakiraman
- Department of Biotechnology, Indian Institute of Technology Madras, Chennai, 600036, India.
| | - V V R Sai
- Biomedical Engineering Division, Department of Applied Mechanics, Indian Institute of Technology Madras, Chennai, 600036, India.
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Huerga H, Cossa L, Manhiça I, Bastard M, Telnov A, Molfino L, Sanchez-Padilla E. Systematic, Point-of-Care Urine Lipoarabinomannan (Alere TB-LAM) Assay for Diagnosing Tuberculosis in Severely Immunocompromised HIV-Positive Ambulatory Patients. Am J Trop Med Hyg 2020; 102:562-566. [PMID: 31971152 PMCID: PMC7056443 DOI: 10.4269/ajtmh.19-0493] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Point-of-care urine-lipoarabinomannan (LAM) Alere Determine TB-LAM assay has shown utility diagnosing tuberculosis (TB) in HIV-positive, severely immunocompromised, TB-symptomatic patients. We assessed LAM results in severely immunocompromised patients, who had LAM systematically performed at new or follow-up HIV consultations. This was a prospective, observational study on consecutive ambulatory, > 15-year-old HIV-positive patients with CD4 < 100 cells/µL in Mozambique. Clinical assessments and LAM were performed for all and microscopy, Xpert, sputum culture, and chest X-ray for LAM-positive participants. Patients were followed up for 6 months. Of 360 patients, half were ART-naive. Lipoarabinomannan positivity was 11.9% (43/360), higher among symptomatic patients compared with asymptomatic: 18.5% (30/162), and 6.6% (13/198), respectively, P = 0.001. Tuberculosis was bacteriologically confirmed in 6/35 LAM-positive patients (2 of them asymptomatic). Lipoarabinomannan positivity was associated with higher risk of mortality (adjusted odds ratio [aOR]: 4.6, 95% CI: 1.3–15.6, P = 0.015). Systematic urine-LAM allows for rapid TB treatment initiation in severely immunocompromised HIV ambulatory patients and identifies patients at a higher risk of death.
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Affiliation(s)
| | - Loide Cossa
- Médecins Sans Frontières, Maputo, Mozambique
| | - Ivan Manhiça
- National Tuberculosis Program, Ministry of Health, Maputo, Mozambique
| | | | - Alex Telnov
- Médecins Sans Frontières, Geneva, Switzerland
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30
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Corleis B, Bucsan AN, Deruaz M, Vrbanac VD, Lisanti-Park AC, Gates SJ, Linder AH, Paer JM, Olson GS, Bowman BA, Schiff AE, Medoff BD, Tager AM, Luster AD, Khader SA, Kaushal D, Kwon DS. HIV-1 and SIV Infection Are Associated with Early Loss of Lung Interstitial CD4+ T Cells and Dissemination of Pulmonary Tuberculosis. Cell Rep 2020; 26:1409-1418.e5. [PMID: 30726727 PMCID: PMC6417097 DOI: 10.1016/j.celrep.2019.01.021] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 11/25/2018] [Accepted: 01/04/2019] [Indexed: 02/07/2023] Open
Abstract
Lung interstitial CD4+ T cells are critical for protection against pulmonary infections, but the fate of this population during HIV-1 infection is not well described. We studied CD4+ T cells in the setting of HIV-1 infection in human lung tissue, humanized mice, and a Mycobacterium tuberculosis (Mtb)/simian immunodeficiency virus (SIV) nonhuman primate co-infection model. Infection with a CCR5-tropic strain of HIV-1 or SIV results in severe and rapid loss of lung interstitial CD4+ T cells but not blood or lung alveolar CD4+ T cells. This is accompanied by high HIV-1 production in these cells in vitro and in vivo. Importantly, during early SIV infection, loss of lung interstitial CD4+ T cells is associated with increased dissemination of pulmonary Mtb infection. We show that lung interstitial CD4+ T cells serve as an efficient target for HIV-1 and SIV infection that leads to their early depletion and an increased risk of disseminated tuberculosis. Corleis et al. show that lung parenchymal CD4+ T cells are permissive to HIV-1-dependent cell death. CD4+ T cell loss is highly significant in the interstitium but not the alveolar space, and loss of interstitial CD4+ T cells is associated with extrapulmonary dissemination of M. tuberculosis.
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Affiliation(s)
- Björn Corleis
- Ragon Institute of MGH, MIT, and Harvard, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Allison N Bucsan
- Tulane National Primate Research Center, Covington, LA, USA; Department of Microbiology and Immunology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Maud Deruaz
- Ragon Institute of MGH, MIT, and Harvard, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Vladimir D Vrbanac
- Ragon Institute of MGH, MIT, and Harvard, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Antonella C Lisanti-Park
- Ragon Institute of MGH, MIT, and Harvard, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Samantha J Gates
- Ragon Institute of MGH, MIT, and Harvard, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Alice H Linder
- Ragon Institute of MGH, MIT, and Harvard, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeffrey M Paer
- Ragon Institute of MGH, MIT, and Harvard, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory S Olson
- Ragon Institute of MGH, MIT, and Harvard, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Brittany A Bowman
- Ragon Institute of MGH, MIT, and Harvard, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Abigail E Schiff
- Ragon Institute of MGH, MIT, and Harvard, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Benjamin D Medoff
- Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA; Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew M Tager
- Ragon Institute of MGH, MIT, and Harvard, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA; Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew D Luster
- Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Shabaana A Khader
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Deepak Kaushal
- Tulane National Primate Research Center, Covington, LA, USA; Southwest National Primate Research Center, San Antonio, TX, USA
| | - Douglas S Kwon
- Ragon Institute of MGH, MIT, and Harvard, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
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31
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Cresswell FV, Ellis J, Kagimu E, Bangdiwala AS, Okirwoth M, Mugumya G, Rutakingirwa M, Kasibante J, Quinn CM, Ssebambulidde K, Rhein J, Nuwagira E, Tugume L, Martyn E, Skipper CP, Muzoora C, Grint D, Meya DB, Bahr NC, Elliott AM, Boulware DR. Standardized Urine-Based Tuberculosis (TB) Screening With TB-Lipoarabinomannan and Xpert MTB/RIF Ultra in Ugandan Adults With Advanced Human Immunodeficiency Virus Disease and Suspected Meningitis. Open Forum Infect Dis 2020; 7:ofaa100. [PMID: 32373646 PMCID: PMC7192026 DOI: 10.1093/ofid/ofaa100] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 03/20/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Diagnosis of extrapulmonary tuberculosis (TB) remains challenging. We sought to determine the prevalence of disseminated TB by testing urine with TB-lipoarabinomannan (TB-LAM) lateral flow assay and Xpert MTB/RIF Ultra (Ultra) in hospitalized adults. METHODS We prospectively enrolled human immunodeficiency virus (HIV)-positive adults with suspected meningitis in Uganda during 2018-2020. Participants underwent standardized urine-based TB screening. Urine (60 mcL) was tested with TB-LAM (Alere), and remaining urine was centrifuged with the cell pellet resuspended in 2 mL of urine for Xpert Ultra testing. RESULTS We enrolled 348 HIV-positive inpatients with median CD4 of 37 cells/mcL (interquartile range, 13-102 cells/mcL). Overall, 26% (90 of 348; 95% confidence interval [CI], 21%-30%) had evidence of disseminated TB by either urine assay. Of 243 participants with both urine TB-LAM and Ultra results, 20% (48 of 243) were TB-LAM-positive, 12% (29 of 243) were Ultra-positive, and 6% (14 of 243) were positive by both assays. In definite and probable TB meningitis, 37% (14 of 38) were TB-LAM-positive and 41% (15 of 37) were Ultra-positive. In cryptococcal meningitis, 22% (40 of 183) were TB-LAM-positive and 4.4% (6 of 135) were Ultra-positive. Mortality trended higher in those with evidence of disseminated TB by either assay (odds ratio = 1.44; 95% CI, 0.83-2.49; P = .19) and was 6-fold higher in those with definite TB meningitis who were urine Ultra-positive (odds ratio = 5.67; 95% CI, 1.13-28.5; P = .04). CONCLUSIONS In hospitalized Ugandans with advanced HIV disease and suspected meningitis, systematic screening with urine TB-LAM and Ultra found a high prevalence of urine TB test positivity (26%). In those with TB meningitis, urine tests were positive in over one third. There was little concordance between Ultra and TB-LAM, which warrants further investigation.
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Affiliation(s)
- Fiona V Cresswell
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- MRC-UVRI-London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Jayne Ellis
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Ananta S Bangdiwala
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Michael Okirwoth
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Gerald Mugumya
- Microbiology Laboratory, Kiruddu Referral Hospital, Kampala, Uganda
| | | | - John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Carson M Quinn
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Joshua Rhein
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, Kansas, USA
| | - Edwin Nuwagira
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Emily Martyn
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Caleb P Skipper
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Conrad Muzoora
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Daniel Grint
- Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, Kansas, USA
| | - Alison M Elliott
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- MRC-UVRI-London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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32
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Mathabire Rucker SC, Cossa L, Harrison RE, Mpunga J, Lobo S, Kisaka Kimupelenge P, Mandar Kol'Ampwe F, Amoros Quiles I, Molfino L, Szumilin E, Telnov O, Ndlovu Z, Huerga H. Feasibility of using Determine TB-LAM to diagnose tuberculosis in HIV-positive patients in programmatic conditions: a multisite study. Glob Health Action 2020; 12:1672366. [PMID: 31610754 PMCID: PMC6807865 DOI: 10.1080/16549716.2019.1672366] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background: Determine TB-LAM is a urine-based point-of-care assay for diagnosis of tuberculosis (TB). Objective: To assess the feasibility of using LAM to diagnose TB in adult HIV-positive patients in resource-limited settings. Methods: We performed a multi-centric mixed-methods cross-sectional descriptive study in the Democratic Republic of Congo, Malawi, and Mozambique. We used the study and program monitoring tools to estimate user workload, turn-around time (TAT), and proportion of patients with LAM and sputum-based results. We conducted semi-structured interviews to assess the user acceptability of the LAM. Results: The duration of the LAM testing activity per patient was 27 min (IQR 26–29); staff continued with other duties whilst waiting for the result. More patients had a LAM versus a sputum-based result: 168/213 (78.9%) vs 77/213 (36.1%), p < 0.001 in DRC; 691/695 (99.4%) vs 429/695 (61.7%), p < 0.001 in Malawi; and 646/647 (99.8%) vs 262/647 (40.5%), p < 0.001 in Mozambique. The median TAT in minutes when LAM was performed in the consultation room was 75 (IQR 45–188) in DRC, 29 (IQR 27–39) in Malawi, and 36 (IQR 35–41) in Mozambique. In comparison, the overall median TAT for sputum-based tests (smear or GeneXpert) was 2 (IQR 1–3) days. The median time to the first anti-TB drug dose for LAM-positive patients was 155 (IQR 90–504) minutes in DRC and 90 (IQR 60–117) minutes in Mozambique. The overall inter-reader agreement for the interpretation of the LAM result as positive or negative was 98.9%, kappa 0.97 (95%CI 0.96–0.99). Overall, LAM users found the test easy to perform. Major concerns were use of the reading card and the prior requirement of CD4 results before LAM testing. Conclusion: It is feasible to implement the LAM test in low resource settings. The short TAT permitted same day initiation of TB treatment for LAM-positive patients.
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Affiliation(s)
| | - Loide Cossa
- Médecins Sans Frontières , Maputo , Mozambique
| | | | | | | | | | | | | | | | | | | | - Zibusiso Ndlovu
- Medecins Sans Frontières, Southern Africa Medical Unit , Cape Town , South Africa
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33
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Kerkhoff AD, Sossen B, Schutz C, Reipold EI, Trollip A, Moreau E, Schumacher SG, Burton R, Ward A, Nicol MP, Meintjes G, Denkinger CM, Broger T. Diagnostic sensitivity of SILVAMP TB-LAM (FujiLAM) point-of-care urine assay for extra-pulmonary tuberculosis in people living with HIV. Eur Respir J 2020; 55:13993003.01259-2019. [PMID: 31699835 PMCID: PMC7002975 DOI: 10.1183/13993003.01259-2019] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 10/18/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Andrew D Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine at Zuckerberg San Francisco General Hospital and Trauma Center, Dept of Medicine, University of California, San Francisco, CA, USA .,Contributed equally
| | - Bianca Sossen
- 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, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Contributed equally
| | - 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, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | | | | | | | | | - Rosie Burton
- Southern African Medical Unit, Médecins sans Frontières, Cape Town, South Africa
| | - Amy Ward
- 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, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Mark P Nicol
- Division of Infection and Immunity, School of Biomedical Sciences, University of Western Australia, Perth, Australia.,Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - 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, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Claudia M Denkinger
- FIND, Geneva, Switzerland.,Division of Tropical Medicine, University of Heidelberg, Heidelberg, Germany.,Contributed equally
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Pardo-Vargas A, Bharate P, Delbianco M, Seeberger PH. Automated glycan assembly of arabinomannan oligosaccharides from Mycobacterium tuberculosis. Beilstein J Org Chem 2019; 15:2936-2940. [PMID: 31839840 PMCID: PMC6902893 DOI: 10.3762/bjoc.15.288] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 11/28/2019] [Indexed: 12/12/2022] Open
Abstract
Arabinomannan (AM) polysaccharides are clinical biomarkers for Mycobacterium tuberculosis (MTB) infections due to their roles in the interaction with host cells and interference with macrophage activation. Collections of defined AM oligosaccharides can help to improve the understanding of these polysaccharides and the development of novel therapeutical and diagnostic agents. Automated glycan assembly (AGA) was employed to prepare the core structure of AM from MTB, containing α-(1,6)-Man, α-(1,5)-Ara, and α-(1,2)-Man linkages. The introduction of a capping step after each glycosylation and further optimized reaction conditions allowed for the synthesis of a series of oligosaccharides, ranging from hexa- to branched dodecasaccharides.
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Affiliation(s)
- Alonso Pardo-Vargas
- Department of Biomolecular Systems, Max-Planck-Institute of Colloids and Interfaces, Am Mühlenberg 1, 14476 Potsdam, Germany.,Institute of Chemistry and Biochemistry, Freie Universität Berlin, Arnimallee 22, 14195 Berlin, Germany
| | - Priya Bharate
- Department of Biomolecular Systems, Max-Planck-Institute of Colloids and Interfaces, Am Mühlenberg 1, 14476 Potsdam, Germany
| | - Martina Delbianco
- Department of Biomolecular Systems, Max-Planck-Institute of Colloids and Interfaces, Am Mühlenberg 1, 14476 Potsdam, Germany
| | - Peter H Seeberger
- Department of Biomolecular Systems, Max-Planck-Institute of Colloids and Interfaces, Am Mühlenberg 1, 14476 Potsdam, Germany.,Institute of Chemistry and Biochemistry, Freie Universität Berlin, Arnimallee 22, 14195 Berlin, Germany
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35
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Bjerrum S, Schiller I, Dendukuri N, Kohli M, Nathavitharana RR, Zwerling AA, Denkinger CM, Steingart KR, Shah M. Lateral flow urine lipoarabinomannan assay for detecting active tuberculosis in people living with HIV. Cochrane Database Syst Rev 2019; 10:CD011420. [PMID: 31633805 PMCID: PMC6802713 DOI: 10.1002/14651858.cd011420.pub3] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The lateral flow urine lipoarabinomannan (LF-LAM) assay Alere Determine™ TB LAM Ag is recommended by the World Health Organization (WHO) to help detect active tuberculosis in HIV-positive people with severe HIV disease. This review update asks the question, "does new evidence justify the use of LF-LAM in a broader group of people?", and is part of the WHO process for updating guidance on the use of LF-LAM. OBJECTIVES To assess the accuracy of LF-LAM for the diagnosis of active tuberculosis among HIV-positive adults with signs and symptoms of tuberculosis (symptomatic participants) and among HIV-positive adults irrespective of signs and symptoms of tuberculosis (unselected participants not assessed for tuberculosis signs and symptoms).The proposed role for LF-LAM is as an add on to clinical judgement and with other tests to assist in diagnosing tuberculosis. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register; MEDLINE, Embase, Science Citation Index, Web of Science, Latin American Caribbean Health Sciences Literature, Scopus, the WHO International Clinical Trials Registry Platform, the International Standard Randomized Controlled Trial Number Registry, and ProQuest, without language restriction to 11 May 2018. SELECTION CRITERIA Randomized trials, cross-sectional, and observational cohort studies that evaluated LF-LAM for active tuberculosis (pulmonary and extrapulmonary) in HIV-positive adults. We included studies that used the manufacturer's recommended threshold for test positivity, either the updated reference card with four bands (grade 1 of 4) or the corresponding prior reference card grade with five bands (grade 2 of 5). The reference standard was culture or nucleic acid amplification test from any body site (microbiological). We considered a higher quality reference standard to be one in which two or more specimen types were evaluated for tuberculosis diagnosis and a lower quality reference standard to be one in which only one specimen type was evaluated. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data using a standardized form and REDCap electronic data capture tools. We appraised the quality of studies using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool and performed meta-analyses to estimate pooled sensitivity and specificity using a bivariate random-effects model and a Bayesian approach. We analyzed studies enrolling strictly symptomatic participants separately from those enrolling unselected participants. We investigated pre-defined sources of heterogeneity including the influence of CD4 count and clinical setting on the accuracy estimates. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included 15 unique studies (nine new studies and six studies from the original review that met the inclusion criteria): eight studies among symptomatic adults and seven studies among unselected adults. All studies were conducted in low- or middle-income countries. Risk of bias was high in the patient selection and reference standard domains, mainly because studies excluded participants unable to produce sputum and used a lower quality reference standard.Participants with tuberculosis symptomsLF-LAM pooled sensitivity (95% credible interval (CrI) ) was 42% (31% to 55%) (moderate-certainty evidence) and pooled specificity was 91% (85% to 95%) (very low-certainty evidence), (8 studies, 3449 participants, 37% with tuberculosis).For a population of 1000 people where 300 have microbiologically-confirmed tuberculosis, the utilization of LF-LAM would result in: 189 to be LF-LAM positive: of these, 63 (33%) would not have tuberculosis (false-positives); and 811 to be LF-LAM negative: of these, 174 (21%) would have tuberculosis (false-negatives).By clinical setting, pooled sensitivity was 52% (40% to 64%) among inpatients versus 29% (17% to 47%) among outpatients; and pooled specificity was 87% (78% to 93%) among inpatients versus 96% (91% to 99%) among outpatients. Stratified by CD4 cell count, pooled sensitivity increased, and specificity decreased with lower CD4 cell count.Unselected participants not assessed for signs and symptoms of tuberculosisLF-LAM pooled sensitivity was 35% (22% to 50%), (moderate-certainty evidence) and pooled specificity was 95% (89% to 96%), (low-certainty evidence), (7 studies, 3365 participants, 13% with tuberculosis).For a population of 1000 people where 100 have microbiologically-confirmed tuberculosis, the utilization of LF-LAM would result in: 80 to be LF-LAM positive: of these, 45 (56%) would not have tuberculosis (false-positives); and 920 to be LF-LAM negative: of these, 65 (7%) would have tuberculosis (false-negatives).By clinical setting, pooled sensitivity was 62% (41% to 83%) among inpatients versus 31% (18% to 47%) among outpatients; pooled specificity was 84% (48% to 96%) among inpatients versus 95% (87% to 99%) among outpatients. Stratified by CD4 cell count, pooled sensitivity increased, and specificity decreased with lower CD4 cell count. AUTHORS' CONCLUSIONS We found that LF-LAM has a sensitivity of 42% to diagnose tuberculosis in HIV-positive individuals with tuberculosis symptoms and 35% in HIV-positive individuals not assessed for tuberculosis symptoms, consistent with findings reported previously. Regardless of how people are enrolled, sensitivity is higher in inpatients and those with lower CD4 cell, but a concomitant lower specificity. As a simple point-of-care test that does not depend upon sputum evaluation, LF-LAM may assist with the diagnosis of tuberculosis, particularly when a sputum specimen cannot be produced.
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Affiliation(s)
- Stephanie Bjerrum
- University of Southern DenmarkDepartment of Clinical Research, Research Unit of Infectious DiseasesOdenseDenmark
- Odense University HospitalMyCRESD, Mycobacterial Research Centre of Southern Denmark, Department of Infectious DiseasesSdr. Boulevard 29OdenseDenmark
- Odense University HospitalOPEN, Odense Patient data Explorative NetworkOdenseDenmarkDenmark
| | - Ian Schiller
- McGill University Health Centre ‐ Research InstituteDivision of Clinical EpidemiologyMontrealQCCanada
| | - Nandini Dendukuri
- McGill University Health Centre ‐ Research InstituteDivision of Clinical EpidemiologyMontrealQCCanada
| | - Mikashmi Kohli
- McGill UniversityDepartment of Epidemiology, Biostatistics and Occupational HealthMontrealCanada
| | - Ruvandhi R Nathavitharana
- Beth Israel Deaconess Medical Center, Harvard Medical SchoolDivision of Infectious DiseasesBostonUSA
| | - Alice A Zwerling
- University of OttawaSchool of Epidemiology & Public Health600 Peter Morand Crescent, Room 301EOttawaOntarioCanadaK1G5Z3
| | - Claudia M Denkinger
- FINDGenevaSwitzerland
- University Hospital HeidelbergCenter of Infectious DiseasesHeidelbergGermany
| | - Karen R Steingart
- Department of Clinical Sciences, Liverpool School of Tropical MedicineHonorary Research FellowPembroke PlaceLiverpoolUK
| | - Maunank Shah
- John Hopkins University School of MedicineDepartment of Medicine, Division of Infectious DiseasesBaltimoreMarylandUSA
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Sinkov VV, Ogarkov OB, Plotnikov AO, Gogoleva NE, Zhdanova SN, Pervanchuk VL, Belkova NL, Koshcheev ME, Thomas TA, Liu J, Zorkaltseva EY, Heysell SK. Metagenomic analysis of mycobacterial transrenal DNA in patients with HIV and tuberculosis coinfection. INFECTION GENETICS AND EVOLUTION 2019; 77:104057. [PMID: 31629083 DOI: 10.1016/j.meegid.2019.104057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 09/23/2019] [Accepted: 09/29/2019] [Indexed: 10/25/2022]
Abstract
The existence of "transrenal" DNA (tr-DNA), i.e. cell-free DNA that has distributed through the renal barrier to the urine, was first shown from a pathogen in 2000 (Botezatu et al., 2000). However, a targeted search for tr-DNA from Mycobacterium tuberculosis (MBT) started relatively recently (Cannas et al., 2008; Green et al., 2009). While other MBT cellular components found in the urine, e.g. lipoarabinomannan, have been used as an enhanced diagnostic tool, tr-DNA has the potential for strain specific identification or a more persistent biomarker during treatment of active disease. We therefore sought to identify by high-throughput next generation sequencing (NGS) MBT genome fragments in the urine of people with human immunodeficiency virus and tuberculosis (HIV-TB) co-infection living in a co-epidemic setting, and to evaluate whether these DNA targets are suitable for the development a quantitative TaqMan polymerase chain reaction with real-time detection (rt-PCR). Selection and mapping to the reference MBT genome of strain H37Rv (NC_000962) revealed 158 fragments of mycobacterial DNA with length from 19 to 44 base pairs (bp) repeated in different DNA samples. Five targets were chosen for design of rt-PCR primers and probes. Comparative analysis of the newly developed tests that were based on the results of NGS did not reveal a significant increase in sensitivity and specificity relative to the previous empirically designed targets. Howver, highly reproducible NGS reads of mycobacterial tr-DNA were obtained. rt-PCR test development suitable for more practical clinical use was likely limited by the small size of the secreted DNA fragments. It is necessary to develop further molecular approaches for the detection of mycobacterial tr-DNA or rely on NGS techniques with inherent bioinformatics requirements.
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Affiliation(s)
- Viacheslav V Sinkov
- Department of Epidemiology and Microbiology, "Scientific Centre for Family Health and Human Reproduction Problems", Irkutsk, Russia
| | - Oleg B Ogarkov
- Department of Epidemiology and Microbiology, "Scientific Centre for Family Health and Human Reproduction Problems", Irkutsk, Russia; Irkutsk State Medical Academy of Continuing Education, Irkutsk, Russia.
| | - Andrey O Plotnikov
- Center of Shared Scientific Equipment "Persistence of microorganisms", Institute for Cellular and Intracellular Symbiosis, Ural Branch of Russian Academy of Sciences, Orenburg, Russia
| | - Natalya E Gogoleva
- Center of Shared Scientific Equipment "Persistence of microorganisms", Institute for Cellular and Intracellular Symbiosis, Ural Branch of Russian Academy of Sciences, Orenburg, Russia; Kazan Institute of Biochemistry and Biophysics, Russian Academy of Sciences, Kazan, Russia
| | - Svetlana N Zhdanova
- Department of Epidemiology and Microbiology, "Scientific Centre for Family Health and Human Reproduction Problems", Irkutsk, Russia
| | | | - Natalia L Belkova
- Limnological Institute Siberian Branch of the Russian Academy of Sciences, Irkutsk, Russia
| | | | - Tania A Thomas
- Division of Infectious Diseases and International Health, University of Virginia, Virginia, USA
| | - Jie Liu
- Division of Infectious Diseases and International Health, University of Virginia, Virginia, USA
| | | | - Scott K Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Virginia, USA
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Bharuthram N, Feldman C. The diagnostic utility of bone marrow examination in an infectious disease ward. South Afr J HIV Med 2019; 20:974. [PMID: 31616572 PMCID: PMC6780001 DOI: 10.4102/sajhivmed.v20i1.974] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 06/05/2019] [Indexed: 12/29/2022] Open
Abstract
Background Patients with advanced human immunodeficiency virus often present with unexplained fevers or cytopenias. Bone marrow aspirate and trephine examinations are an invasive means to aid diagnoses in patients who present with diagnostic dilemmas. Objectives A retrospective record review to assess the diagnostic utility of bone marrow examinations in a South African Infectious Diseases ward. Methods The records of patients who had undergone a bone marrow examination in the Infectious Disease ward at the Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa, between 01 January 2012 and 31 December 2014 were reviewed. A unique diagnosis was considered to be any diagnosis made on bone marrow examination alone, or a diagnosis made more timeously on bone marrow examination than with alternative investigations. Results Of 327 patients who underwent bone marrow examination, 80 unique diagnoses were obtained in 77 cases (23.5%). The unique diagnoses included the presence of granuloma (n = 49), Mycobacterium tuberculosis (n = 17), Mycobacterium avium complex (n = 3), haematological malignancy (n = 4) and pure red cell aplasia (n = 5). A white cell count ≤ 4 × 109/L predicted a unique outcome (p < 0.01). A white cell count ≤ 4 × 109/L and CD4 cell count ≤ 50 cells/mm3 predicted mycobacterial infection of the bone marrow. Conclusions The findings of a unique diagnosis in 23.5% of bone marrow examinations performed suggests that this remains a useful investigative modality in patients in whom less invasive investigations have not yielded a diagnosis.
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Affiliation(s)
- Nirvana Bharuthram
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Charles Feldman
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Urogenital tuberculosis - epidemiology, pathogenesis and clinical features. Nat Rev Urol 2019; 16:573-598. [PMID: 31548730 DOI: 10.1038/s41585-019-0228-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2019] [Indexed: 02/07/2023]
Abstract
Tuberculosis (TB) is the most common cause of death from infectious disease worldwide. A substantial proportion of patients presenting with extrapulmonary TB have urogenital TB (UG-TB), which can easily be overlooked owing to non-specific symptoms, chronic and cryptic protean clinical manifestations, and lack of clinician awareness of the possibility of TB. Delay in diagnosis results in disease progression, irreversible tissue and organ damage and chronic renal failure. UG-TB can manifest with acute or chronic inflammation of the urinary or genital tract, abdominal pain, abdominal mass, obstructive uropathy, infertility, menstrual irregularities and abnormal renal function tests. Advanced UG-TB can cause renal scarring, distortion of renal calyces and pelvic, ureteric strictures, stenosis, urinary outflow tract obstruction, hydroureter, hydronephrosis, renal failure and reduced bladder capacity. The specific diagnosis of UG-TB is achieved by culturing Mycobacterium tuberculosis from an appropriate clinical sample or by DNA identification. Imaging can aid in localizing site, extent and effect of the disease, obtaining tissue samples for diagnosis, planning medical or surgical management, and monitoring response to treatment. Drug-sensitive TB requires 6-9 months of WHO-recommended standard treatment regimens. Drug-resistant TB requires 12-24 months of therapy with toxic drugs with close monitoring. Surgical intervention as an adjunct to medical drug treatment is required in certain circumstances. Current challenges in UG-TB management include making an early diagnosis, raising clinical awareness, developing rapid and sensitive TB diagnostics tests, and improving treatment outcomes.
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Kubiak RW, Herbeck JT, Coleman SM, Ross D, Freedberg K, Bassett IV, Drain PK. Urinary LAM grade, culture positivity, and mortality among HIV-infected South African out-patients. Int J Tuberc Lung Dis 2019; 22:1366-1373. [PMID: 30355418 DOI: 10.5588/ijtld.18.0099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Four ambulatory clinics in Durban, South Africa. OBJECTIVE To test the relationships of patient characteristics, time to mycobacterial culture positivity, and mortality with urinary lipoarabinomannan (LAM) grade category. DESIGN Newly diagnosed human immunodeficiency virus (HIV) infected adults were screened for tuberculosis (TB) using sputum culture, tested for urinary LAM, and followed for up to 12 months. We performed multivariable ordinal logistic regression of risk factors for low (1 or 2) or high (3, 4, or 5) LAM grade. We used adjusted Cox regression models to determine the hazard ratios of time to culture positivity and death. RESULTS Among 683 HIV-infected adults, median CD4 count was 215 cells/mm³ (interquartile range 86-361 cells/mm³), 17% had culture-confirmed TB, and 11% died during follow-up. Smoking, tachycardia (pulse > 100 beats/minute), CD4 count < 100 cells/mm³, and TB culture positivity were each associated with higher LAM grade. In multivariate models, a high urine LAM grade was associated with four-fold increased hazard of culture positivity (P = 0.001) and two-fold increased hazard of mortality (P = 0.02). Among patients treated for TB, these associations were no longer statistically significant. CONCLUSION In this population, a higher urine LAM grade was associated with shorter time to culture positivity and mortality; however, these associations were not present for those starting anti-tuberculosis treatment.
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Affiliation(s)
| | - J T Herbeck
- Global Health, University of Washington, Seattle, Washington
| | - S M Coleman
- Boston University School of Public Health, Boston, Massachusetts, USA
| | - D Ross
- Department of Medicine, St Mary's Hospital, Durban, South Africa
| | - K Freedberg
- Boston University School of Public Health, Boston, Massachusetts, USA, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - I V Bassett
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - P K Drain
- Epidemiology, and, Global Health, University of Washington, Seattle, Washington, Department of Medicine, University of Washington, Seattle, Washington, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Nel JS, Lippincott CK, Berhanu R, Spencer DC, Sanne IM, Ive P. Does Disseminated Nontuberculous Mycobacterial Disease Cause False-Positive Determine TB-LAM Lateral Flow Assay Results? A Retrospective Review. Clin Infect Dis 2019; 65:1226-1228. [PMID: 28575238 DOI: 10.1093/cid/cix513] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 05/28/2017] [Indexed: 12/13/2022] Open
Abstract
We retrospectively reviewed the Determine TB-LAM lateral flow assay (LF-LAM) results among human immunodeficiency virus-infected patients with disseminated nontuberculous mycobacterial (NTM) disease. LF-LAM was positive in 19 of 21 patients without evidence of tuberculosis (TB) coinfection. Although TB-NTM coinfection may have been underdiagnosed, our results suggest that disseminated NTM disease may cause false-positive LF-LAM results.
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Affiliation(s)
- Jeremy S Nel
- Division of Infectious Diseases, Department of Internal Medicine, Helen Joseph Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Christopher K Lippincott
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rebecca Berhanu
- Center for Infectious Diseases, University of North Carolina at Chapel Hill; and
| | | | - Ian M Sanne
- Clinical HIV Research Unit, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Prudence Ive
- Division of Infectious Diseases, Department of Internal Medicine, Helen Joseph Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Schutz C, Barr D, Andrade BB, Shey M, Ward A, Janssen S, Burton R, Wilkinson KA, Sossen B, Fukutani KF, Nicol M, Maartens G, Wilkinson RJ, Meintjes G. Clinical, microbiologic, and immunologic determinants of mortality in hospitalized patients with HIV-associated tuberculosis: A prospective cohort study. PLoS Med 2019; 16:e1002840. [PMID: 31276515 PMCID: PMC6611568 DOI: 10.1371/journal.pmed.1002840] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 05/24/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND In high-burden settings, case fatality rates are reported to be between 11% and 32% in hospitalized patients with HIV-associated tuberculosis, yet the underlying causes of mortality remain poorly characterized. Understanding causes of mortality could inform the development of novel management strategies to improve survival. We aimed to assess clinical and microbiologic determinants of mortality and to characterize the pathophysiological processes underlying death by evaluating host soluble inflammatory mediators and determined the relationship between these mediators and death as well as biomarkers of disseminated tuberculosis. METHODS AND FINDINGS Adult patients with HIV hospitalized with a new diagnosis of HIV-associated tuberculosis were enrolled in Cape Town between 2014 and 2016. Detailed tuberculosis diagnostic testing was performed. Biomarkers of tuberculosis dissemination and host soluble inflammatory mediators at baseline were assessed. Of 682 enrolled participants, 576 with tuberculosis (487/576, 84.5% microbiologically confirmed) were included in analyses. The median age was 37 years (IQR = 31-43), 51.2% were female, and the patients had advanced HIV with a median cluster of differentiation 4 (CD4) count of 58 cells/L (IQR = 21-120) and a median HIV viral load of 5.1 log10 copies/mL (IQR = 3.3-5.7). Antituberculosis therapy was initiated in 566/576 (98.3%) and 487/576 (84.5%) started therapy within 48 hours of enrolment. Twelve-week mortality was 124/576 (21.5%), with 46/124 (37.1%) deaths occurring within 7 days of enrolment. Clinical and microbiologic determinants of mortality included disseminated tuberculosis (positive urine lipoarabinomannan [LAM], urine Xpert MTB/RIF, or tuberculosis blood culture in 79.6% of deaths versus 60.7% of survivors, p = 0.001), sepsis syndrome (high lactate in 50.8% of deaths versus 28.9% of survivors, p < 0.001), and rifampicin-resistant tuberculosis (16.9% of deaths versus 7.2% of survivors, p = 0.002). Using non-supervised two-way hierarchical cluster and principal components analyses, we describe an immune profile dominated by mediators of the innate immune system and chemotactic signaling (interleukin-1 receptor antagonist [IL-1Ra], IL-6, IL-8, macrophage inflammatory protein-1 beta [MIP-1β]/C-C motif chemokine ligand 4 [CCL4], interferon gamma-induced protein-10 [IP-10]/C-X-C motif chemokine ligand 10 [CXCL10], MIP-1 alpha [MIP-1α]/CCL3), which segregated participants who died from those who survived. This immune profile was associated with mortality in a Cox proportional hazards model (adjusted hazard ratio [aHR] = 2.2, 95%CI = 1.9-2.7, p < 0.001) and with detection of biomarkers of disseminated tuberculosis. Clinicians attributing causes of death identified tuberculosis as a cause or one of the major causes of death in 89.5% of cases. We did not perform longitudinal sampling and did not have autopsy-confirmed causes of death. CONCLUSIONS In this study, we did not identify a major contribution from coinfections to these deaths. Disseminated tuberculosis, sepsis syndrome, and rifampicin resistance were associated with mortality. An immune profile dominated by mediators of the innate immune system and chemotactic signaling was associated with both tuberculosis dissemination and mortality. These findings provide pathophysiologic insights into underlying causes of mortality and could be used to inform the development of novel treatment strategies and to develop methods to risk stratify patients to appropriately target novel interventions. Causal relationships cannot be established from this study.
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Affiliation(s)
- Charlotte Schutz
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - David Barr
- Wellcome Trust Liverpool Glasgow Centre for Global Health Research, University of Liverpool, Liverpool, United Kingdom
| | - Bruno B. Andrade
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Universidade Salvador (UNIFACS), Laureate Universities, Salvador, Brazil
| | - Muki Shey
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Amy Ward
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Saskia Janssen
- Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Rosie Burton
- Khayelitsha Hospital, Department of Medicine, Cape Town, South Africa
| | - Katalin A. Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- The Francis Crick Institute, London, United Kingdom
| | - Bianca Sossen
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kiyoshi F. Fukutani
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
- Faculdade de Tecnologia e Ciências (FTC), Salvador, Brazil
| | - Mark Nicol
- Division of Medical Microbiology, University of Cape Town and National Health Laboratory Services, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Robert J. Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- The Francis Crick Institute, London, United Kingdom
- Department of Medicine, Imperial College, London, United Kingdom
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
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Abstract
Tuberculosis remains the leading cause of death from an infectious disease among adults worldwide, with more than 10 million people becoming newly sick from tuberculosis each year. Advances in diagnosis, including the use of rapid molecular testing and whole-genome sequencing in both sputum and non-sputum samples, could change this situation. Although little has changed in the treatment of drug-susceptible tuberculosis, data on increased efficacy with new and repurposed drugs have led WHO to recommend all-oral therapy for drug-resistant tuberculosis for the first time ever in 2018. Studies have shown that shorter latent tuberculosis prevention regimens containing rifampicin or rifapentine are as effective as longer, isoniazid-based regimens, and there is a promising vaccine candidate to prevent the progression of infection to the disease. But new tools alone are not sufficient. Advances must be made in providing high-quality, people-centred care for tuberculosis. Renewed political will, coupled with improved access to quality care, could relegate the morbidity, mortality, and stigma long associated with tuberculosis, to the past.
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Affiliation(s)
- Jennifer Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.
| | - Helen Cox
- Division of Medical Microbiology and the Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Madhukar Pai
- McGill International Tuberculosis Centre, McGill University, Montreal, QC, Canada; Manipal McGill Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, India
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Risk score for predicting mortality including urine lipoarabinomannan detection in hospital inpatients with HIV-associated tuberculosis in sub-Saharan Africa: Derivation and external validation cohort study. PLoS Med 2019; 16:e1002776. [PMID: 30951533 PMCID: PMC6450614 DOI: 10.1371/journal.pmed.1002776] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 03/06/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The prevalence of and mortality from HIV-associated tuberculosis (HIV/TB) in hospital inpatients in Africa remains unacceptably high. Currently, there is a lack of tools to identify those at high risk of early mortality who may benefit from adjunctive interventions. We therefore aimed to develop and validate a simple clinical risk score to predict mortality in high-burden, low-resource settings. METHODS AND FINDINGS A cohort of HIV-positive adults with laboratory-confirmed TB from the STAMP TB screening trial (Malawi and South Africa) was used to derive a clinical risk score using multivariable predictive modelling, considering factors at hospital admission (including urine lipoarabinomannan [LAM] detection) thought to be associated with 2-month mortality. Performance was evaluated internally and then externally validated using independent cohorts from 2 other studies (LAM-RCT and a Médecins Sans Frontières [MSF] cohort) from South Africa, Zambia, Zimbabwe, Tanzania, and Kenya. The derivation cohort included 315 patients enrolled from October 2015 and September 2017. Their median age was 36 years (IQR 30-43), 45.4% were female, median CD4 cell count at admission was 76 cells/μl (IQR 23-206), and 80.2% (210/262) of those who knew they were HIV-positive at hospital admission were taking antiretroviral therapy (ART). Two-month mortality was 30% (94/315), and mortality was associated with the following factors included in the score: age 55 years or older, male sex, being ART experienced, having severe anaemia (haemoglobin < 80 g/l), being unable to walk unaided, and having a positive urinary Determine TB LAM Ag test (Alere). The score identified patients with a 46.4% (95% CI 37.8%-55.2%) mortality risk in the high-risk group compared to 12.5% (95% CI 5.7%-25.4%) in the low-risk group (p < 0.001). The odds ratio (OR) for mortality was 6.1 (95% CI 2.4-15.2) in high-risk patients compared to low-risk patients (p < 0.001). Discrimination (c-statistic 0.70, 95% CI 0.63-0.76) and calibration (Hosmer-Lemeshow statistic, p = 0.78) were good in the derivation cohort, and similar in the external validation cohort (complete cases n = 372, c-statistic 0.68 [95% CI 0.61-0.74]). The validation cohort included 644 patients between January 2013 and August 2015. Median age was 36 years, 48.9% were female, and median CD4 count at admission was 61 (IQR 21-145). OR for mortality was 5.3 (95% CI 2.2-9.5) for high compared to low-risk patients (complete cases n = 372, p < 0.001). The score also predicted patients at higher risk of death both pre- and post-discharge. A simplified score (any 3 or more of the predictors) performed equally well. The main limitations of the scores were their imperfect accuracy, the need for access to urine LAM testing, modest study size, and not measuring all potential predictors of mortality (e.g., tuberculosis drug resistance). CONCLUSIONS This risk score is capable of identifying patients who could benefit from enhanced clinical care, follow-up, and/or adjunctive interventions, although further prospective validation studies are necessary. Given the scale of HIV/TB morbidity and mortality in African hospitals, better prognostic tools along with interventions could contribute towards global targets to reduce tuberculosis mortality.
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Huerga H, Mathabire Rucker SC, Cossa L, Bastard M, Amoros I, Manhiça I, Mbendera K, Telnov A, Szumilin E, Sanchez-Padilla E, Molfino L. Diagnostic value of the urine lipoarabinomannan assay in HIV-positive, ambulatory patients with CD4 below 200 cells/μl in 2 low-resource settings: A prospective observational study. PLoS Med 2019; 16:e1002792. [PMID: 31039161 PMCID: PMC6490904 DOI: 10.1371/journal.pmed.1002792] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 03/28/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Current guidelines recommend the use of the lateral flow urine lipoarabinomannan assay (LAM) in HIV-positive, ambulatory patients with signs and symptoms of tuberculosis (TB) only if they are seriously ill or have CD4 count ≤ 100 cells/μl. We assessed the diagnostic yield of including LAM in TB diagnostic algorithms in HIV-positive, ambulatory patients with CD4 < 200 cells/μl, as well as the risk of mortality in LAM-positive patients who were not diagnosed using other diagnostic tools and not treated for TB. METHODS AND FINDINGS We conducted a prospective observational study including HIV-positive adult patients with signs and symptoms of TB and CD4 < 200 cells/μl attending 6 health facilities in Malawi and Mozambique. Patients were included consecutively from 18 September 2015 to 27 October 2016 in Malawi and from 3 December 2014 to 22 August 2016 in Mozambique. All patients had a clinical exam and LAM, chest X-ray, sputum microscopy, and Xpert MTB/RIF assay (Xpert) requested. Culture in sputum was done for a subset of patients. The diagnostic yield was defined as the proportion of patients with a positive assay result among those with laboratory-confirmed TB. For the 456 patients included in the study, the median age was 36 years (IQR 31-43) and the median CD4 count was 50 cells/μl (IQR 21-108). Forty-five percent (205/456) of the patients had laboratory-confirmed TB. The diagnostic yields of LAM, microscopy, and Xpert were 82.4% (169/205), 33.7% (69/205), and 40.0% (84/205), respectively. In total, 50.2% (103/205) of the patients with laboratory-confirmed TB were diagnosed only through LAM. Overall, the use of LAM in diagnostic algorithms increased the yield of algorithms with microscopy and with Xpert by 38.0% (78/205) and 34.6% (71/205), respectively, and, specifically among patients with CD4 100-199 cells/μl, by 27.5% (14/51) and 29.4% (15/51), respectively. LAM-positive patients not diagnosed through other tools and not treated for TB had a significantly higher risk of mortality than LAM-positive patients who received treatment (adjusted risk ratio 2.57, 95% CI 1.27-5.19, p = 0.009). Although the TB diagnostic conditions in the study sites were similar to those in other resource-limited settings, the added value of LAM may depend on the availability of microscopy or Xpert results. CONCLUSIONS LAM has diagnostic value for identifying TB in HIV-positive patients with signs and symptoms of TB and advanced immunodeficiency, including those with a CD4 count of 100-199 cells/μl. In this study, the use of LAM enabled the diagnosis of TB in half of the patients with confirmed TB disease; without LAM, these patients would have been missed. The rapid identification and treatment of TB enabled by LAM may decrease overall mortality risk for these patients.
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Affiliation(s)
| | | | - Loide Cossa
- Médecins Sans Frontières, Maputo, Mozambique
| | | | | | | | | | - Alex Telnov
- Médecins Sans Frontières, Geneva, Switzerland
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45
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Andriyoko B, Janiar H, Kusumadewi R, Klinkenberg E, de Haas P, Tiemersma E. Simple stool processing method for the diagnosis of pulmonary tuberculosis using GeneXpert MTB/RIF. Eur Respir J 2019; 53:13993003.01832-2018. [PMID: 30578382 DOI: 10.1183/13993003.01832-2018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 11/24/2018] [Indexed: 11/05/2022]
Affiliation(s)
- Basti Andriyoko
- Molecular Biology Division, Dept of Clinical Pathology, Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Harini Janiar
- KNCV TB Foundation, Indonesia office, Jakarta, Indonesia
| | | | - Eveline Klinkenberg
- KNCV Tuberculosis Foundation, The Hague, The Netherlands.,Dept of Global Health, Amsterdam Institute for Global Health and Development, Academic Medical Centre, Amsterdam, The Netherlands
| | - Petra de Haas
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
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46
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Joon D, Nimesh M, Gupta S, Kumar C, Varma-Basil M, Saluja D. Development and evaluation of rapid and specific sdaA LAMP-LFD assay with Xpert MTB/RIF assay for diagnosis of tuberculosis. J Microbiol Methods 2019; 159:161-166. [PMID: 30858005 DOI: 10.1016/j.mimet.2019.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 03/04/2019] [Accepted: 03/06/2019] [Indexed: 11/19/2022]
Abstract
There is need for rapid and cost-effective diagnostic test for tuberculosis. The present study was carried out to design a Loop-mediated isothermal amplification (LAMP) assay combined with lateral flow dipstick (LFD) as a point-of-care method for diagnosis of TB. LAMP assay targeting sdaA gene combined with LFD for sequence specific detection was standardized in user friendly and rapid format. It does not require sophisticated instruments and shows visual results instantly. The LAMP-LFD assay was validated using culture confirmed specimens. The assay was evaluated in a cross-sectional study using respiratory specimens collected from patients in Delhi, India and it showed high concordance with GeneXpert MTB/RIF assay. Lateral flow dipstick method has provided an excellent detection format with LAMP method. The LAMP-LFD assay showed high diagnostic accuracy in comparison to other methods and can be used as a point-of-care test in cost-effective manner.
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Affiliation(s)
- Deepali Joon
- Dr. B. R. Ambedkar Center for Biomedical Research, University of Delhi, Delhi 110 007, India; Shri Guru Tegh Bahadur Khalsa College, University of Delhi, Delhi 110 007, India
| | - Manoj Nimesh
- Shri Guru Tegh Bahadur Khalsa College, University of Delhi, Delhi 110 007, India
| | - Shraddha Gupta
- Department of Microbiology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi 11007, India
| | - Chanchal Kumar
- Department of Microbiology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi 11007, India
| | - Mandira Varma-Basil
- Department of Microbiology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi 11007, India
| | - Daman Saluja
- Dr. B. R. Ambedkar Center for Biomedical Research, University of Delhi, Delhi 110 007, India.
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Abstract
Implementation science uses methods to promote the scaling up and use of evidence-based practices by health systems to improve quality and outcomes. Its use is vital to maximise the efficiency of limited resources for health care in tropical settings. HIV and tuberculosis (TB) are two of the major causes of morbidity and mortality in sub-Saharan Africa, and globally. Although effective treatments are widely available, lack of diagnosis remains a large barrier to accessing treatment, particularly in resource-limited settings. We explore HIV and TB diagnostics that can be used at point-of-care in any settings, and outline some important principles and applications of implementation science to aid their application and use. Despite robust evidence of diagnostic accuracy and efficacy in improving patient-centred outcomes, such interventions cannot be fully utilised without addressing operational barriers and knowledge gaps.
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Affiliation(s)
- Ankur Gupta-Wright
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
- Department of Infection, St Thomas' Hospital, London, UK
| | - Yukari C Manabe
- Division of Infectious Diseases, Department of Medicine Johns Hopkins School of Medicine, Baltimore, USA
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48
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Atherton RR, Cresswell FV, Ellis J, Kitaka SB, Boulware DR. Xpert MTB/RIF Ultra for Tuberculosis Testing in Children: A Mini-Review and Commentary. Front Pediatr 2019; 7:34. [PMID: 30873392 PMCID: PMC6403143 DOI: 10.3389/fped.2019.00034] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 01/25/2019] [Indexed: 12/12/2022] Open
Abstract
Tuberculosis (TB) remains a significant, yet under-recognized cause of death in the pediatric population, with a WHO estimate of 1 million new cases of childhood TB in 2016 resulting in 250,000 deaths. Diagnosis is notoriously difficult; manifestations are protean due to the high proportion of cases of extra-pulmonary TB in children, and logistical problems exist in obtaining suitable specimens. These issues are compounded by the paucibacillary nature of disease with the result that an estimated 96% of pediatric TB-associated mortality occurs prior to commencing anti-tuberculous treatment. Further development of sensitive, rapid diagnostic tests and their incorporation into diagnostic algorithms is vital in this population, and central to the WHO End-TB strategy. Initial gains were made with the expansion of nucleic acid amplification technology, particularly the introduction of the GeneXpert fully-automated PCR Xpert MTB/Rif assay in 2010, and more recently, the Xpert MTB/Rif Ultra (Ultra) assay in 2017. Ultra provides increased analytical sensitivity when compared with the initial Xpert assay in vitro; a finding now also supported by six clinical studies to date, two of which included pediatric samples. Here, we review the published evidence for the performance of Ultra in TB diagnosis in children, as well as studies in adults with paucibacillary disease providing results relevant to the pediatric population. Following on from this, we speculate upon future directions for Ultra, with focus on its potential use with alternative diagnostic specimens, which may be of particular utility in children.
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Affiliation(s)
- Rachel R. Atherton
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Fiona V. Cresswell
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- LSHTM-MRC-UVRI Uganda Research Unit, Entebbe, Uganda
| | - Jayne Ellis
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Sabrina B. Kitaka
- Department of Paediatrics and Child Health, Mulago Hospital and Makerere University School of Medicine, Kampala, Uganda
| | - David R. Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
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Correia-Neves M, Fröberg G, Korshun L, Viegas S, Vaz P, Ramanlal N, Bruchfeld J, Hamasur B, Brennan P, Källenius G. Biomarkers for tuberculosis: the case for lipoarabinomannan. ERJ Open Res 2019; 5:00115-2018. [PMID: 30775376 PMCID: PMC6368998 DOI: 10.1183/23120541.00115-2018] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 11/05/2018] [Indexed: 02/07/2023] Open
Abstract
Tuberculosis (TB) is considered the most onerous of infectious diseases according to recent reports from the World Health Organization. Available tests for TB diagnosis present severe limitations, and a reliable point-of-care (POC) diagnostic test does not exist. Neither is there a test to discern between the different stages of TB, and in particular to predict which patients with Mycobacterium tuberculosis infection and no clinical signs are more at risk of advancing to overt disease. We here review the usefulness of mycobacterial lipoarabinomannan (LAM) as a diagnostic marker for active and latent TB and, also, aspects of the immune response to LAM relevant to such tests. There is a high potential for urinary LAM-based POC tests for the diagnosis of active TB. Some technical challenges to optimised sensitivity of the test will be detailed. A method to quantify LAM in urine or serum should be further explored as a test of treatment effect. Recent data on the immune response to LAM suggest that markers for host response to LAM should be investigated for a prognostic test to recognise individuals at the greatest risk of disease activation. There is a high potential for a urinary LAM-based point-of-care test to diagnose TB. Markers for host response to LAM should be explored to identify those at highest risk of developing active TB.http://ow.ly/FyCs30n4uFE
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Affiliation(s)
- Margarida Correia-Neves
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal.,Division of Infectious Diseases, Dept of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Gabrielle Fröberg
- Division of Infectious Diseases, Dept of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Dept of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | | | - Sofia Viegas
- Instituto Nacional de Saúde, Ministério da Saúde, Maputo, Mozambique
| | - Paula Vaz
- Instituto Nacional de Saúde, Ministério da Saúde, Maputo, Mozambique.,Fundação Ariel Glaser Contra o SIDA Pediátrico, Maputo, Mozambique
| | - Nehaben Ramanlal
- Fundação Ariel Glaser Contra o SIDA Pediátrico, Maputo, Mozambique
| | - Judith Bruchfeld
- Division of Infectious Diseases, Dept of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Dept of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Beston Hamasur
- Biopromic AB, Solna, Sweden.,Dept of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Patrick Brennan
- Dept of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO, USA
| | - Gunilla Källenius
- Division of Infectious Diseases, Dept of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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Singh A, Somvanshi P, Grover A. Drug repurposing against arabinosyl transferase (EmbC) of Mycobacterium tuberculosis: Essential dynamics and free energy minima based binding mechanics analysis. Gene 2019; 693:114-126. [PMID: 30716439 DOI: 10.1016/j.gene.2019.01.029] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 12/20/2018] [Accepted: 01/02/2019] [Indexed: 01/10/2023]
Abstract
Arabinosyl tranferases (embA, embB, embC) are the key enzymes responsible for biogenesis of arabinan domain of arabinogalactan (AG) and lipoarabinomannan (LAM), two major heteropolysaccharide constituents of the peculiar mycobacterial cell envelope. EmbC is predominantly responsible for LAM synthesis and has been commonly associated with Ethambutol resistance. We have screened the FDA library against EmbC to reposition a drug better than Ethambutol with higher binding affinity to Embc. High throughput virtual screening followed by extra precision docking using Glide gave two best leads i.e. Terlipressin and Amikacin with docking score of -11.39 kcal/mol and -10.71 kcal/mol, respectively. Binding mechanics of the selected drugs was elucidated through long range molecular dynamics simulations (100 ns) using binding free energy rescoring, essential dynamics and free energy minima based approaches, thus revealing the most stable binding modes of Terlipressin with EmbC. Our study establishes the EmbC binding potential of the repurposed drugs Terlipressin and Amikacin.
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Affiliation(s)
- Aditi Singh
- School of Biotechnology, Jawaharlal Nehru University, New Delhi 110067, India; Department of Biotechnology, TERI School of Advanced Studies, Plot No. 10, Vasant Kunj Institutional Area, Vasant Kunj, New Delhi, 110070, India
| | - Pallavi Somvanshi
- Department of Biotechnology, TERI School of Advanced Studies, Plot No. 10, Vasant Kunj Institutional Area, Vasant Kunj, New Delhi, 110070, India.
| | - Abhinav Grover
- School of Biotechnology, Jawaharlal Nehru University, New Delhi 110067, India.
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