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Miyakawa R, Louie J, Keh C, Chen L, Javid B, Ernst JD, Goswami N, Chow FC. A teenage girl with altered mental status and paraparesis. J Clin Tuberc Other Mycobact Dis 2024; 35:100425. [PMID: 38468819 PMCID: PMC10926304 DOI: 10.1016/j.jctube.2024.100425] [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] [Indexed: 03/13/2024] Open
Abstract
A teenage girl presented with fever and altered mental status. MRI showed diffuse leptomeningeal enhancement of the brain and spine. She was diagnosed by a positive cerebrospinal fluid (CSF) culture with tuberculous (TB) meningitis and was started on anti-TB medications and corticosteroids. Her mental status improved, but she was noted to have proximal weakness of the lower extremities. In the course of tapering corticosteroids at week 11 of anti-TB therapy, she became acutely confused and febrile. MRI demonstrated interval development of tuberculomas in the brain and a mass lesion in the thoracic spine causing cord compression. Given the clinical picture was suggestive of a paradoxical reaction, the dose of corticosteroids was increased. Infliximab was added when repeat MRI revealed enlargement of the mass lesion in the spine with worsening cord compression. She was successfully tapered off of corticosteroids. Over several months, the patient's motor function recovered fully, and she returned to ambulating without assistance.
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Affiliation(s)
- Ryo Miyakawa
- Department of Pediatrics, University of California, San Francisco, USA
| | - Janice Louie
- Department of Medicine, University of California, San Francisco, USA
- Department of Public Health, San Francisco, USA
| | - Chris Keh
- Department of Medicine, University of California, San Francisco, USA
- California Department of Public Health, USA
| | - Lisa Chen
- Department of Medicine, University of California, San Francisco, USA
- Curry International Tuberculosis Center, USA
| | - Babak Javid
- Department of Medicine, University of California, San Francisco, USA
| | - Joel D. Ernst
- Department of Medicine, University of California, San Francisco, USA
| | | | - Felicia C. Chow
- Department of Medicine, University of California, San Francisco, USA
- Department of Neurology, University of California, San Francisco, USA
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Bes-Berlandier H, Garzaro M, Rouzaud C, Bodard S, Bille E, Ficheux M, Cazals-Hatem D, Veziris N, Lanternier F, Lortholary O. Successful rescue TNF-α blocking for Mycobacterium genavense - Related immune reconstitution inflammatory syndrome: A case report. Heliyon 2024; 10:e29341. [PMID: 38623247 PMCID: PMC11016716 DOI: 10.1016/j.heliyon.2024.e29341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 04/04/2024] [Accepted: 04/05/2024] [Indexed: 04/17/2024] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) has been reported in immunocompromised patients with disseminated Mycobacterium genavense. Management relies on high-dose corticosteroids. We describe two cases of late-onset corticosteroid-refractory IRIS related to disseminated infection in a HIV-positive patient and a renal transplant patient who had a favorable outcome with a monoclonal TNF-α blocker.
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Affiliation(s)
- Hugo Bes-Berlandier
- Service de Maladies Infectieuses et Tropicales, Hôpital Necker-Enfants-malades, Assistance publique-Hôpitaux de Paris, 149 rue de Sèvres, 75743, Paris, France
| | - Margaux Garzaro
- Service de Maladies Infectieuses et Tropicales, Hôpital Necker-Enfants-malades, Assistance publique-Hôpitaux de Paris, 149 rue de Sèvres, 75743, Paris, France
- Université Paris Cité, 15 rue de l’école de Médecine, 75006, Paris, France
| | - Claire Rouzaud
- Service de Maladies Infectieuses et Tropicales, Hôpital Necker-Enfants-malades, Assistance publique-Hôpitaux de Paris, 149 rue de Sèvres, 75743, Paris, France
| | - Sylvain Bodard
- Université Paris Cité, 15 rue de l’école de Médecine, 75006, Paris, France
- Service de Radiologie adulte, Hôpital-Necker-Enfants-malades, Assistance publique-Hôpitaux de Paris, 149 rue de Sèvres, 75743, Paris, France
| | - Emmanuelle Bille
- Université Paris Cité, 15 rue de l’école de Médecine, 75006, Paris, France
- Service de Microbiologie, Hôpital Necker-Enfants-malades, Assistance publique-Hôpitaux de Paris, 149 rue de Sèvres, 75743, Paris, France
| | - Maxence Ficheux
- Service de Néphrologie, Centre Hospitalier universitaire de Caen Normandie, Avenue de la Côte de Nacre, 14033, Caen, France
| | - Dominique Cazals-Hatem
- Université Paris Cité, 15 rue de l’école de Médecine, 75006, Paris, France
- Département de Pathologie, Hôpital Beaujon, Assistance publique-Hôpitaux de Paris, 100, Boulevard Leclerc, 92118, Clichy, France
| | - Nicolas Veziris
- Sorbonne Université, Centre d'Immunologie et des Maladies Infectieuses (Cimi-Paris), UMR, 1135, Department of Bacteriology, Saint-Antoine Hospital, APHP. Sorbonne-Université, Centre National de Référence des Mycobactéries, Paris, France
| | - Fanny Lanternier
- Service de Maladies Infectieuses et Tropicales, Hôpital Necker-Enfants-malades, Assistance publique-Hôpitaux de Paris, 149 rue de Sèvres, 75743, Paris, France
- Université Paris Cité, 15 rue de l’école de Médecine, 75006, Paris, France
| | - Olivier Lortholary
- Service de Maladies Infectieuses et Tropicales, Hôpital Necker-Enfants-malades, Assistance publique-Hôpitaux de Paris, 149 rue de Sèvres, 75743, Paris, France
- Université Paris Cité, 15 rue de l’école de Médecine, 75006, Paris, France
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Goyal V, Elavarasi A, Kumar A, Samal P, Garg A, Shukla G, Vishnu VY, Singh MB, Srivastava MVP. Cyclophosphamide therapy as an adjunct in refractory post-tubercular arachnoiditis. Indian J Tuberc 2022; 69:325-333. [PMID: 35760482 DOI: 10.1016/j.ijtb.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 05/22/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION There is no satisfactory treatment for post tubercular arachnoiditis (TB arachnoiditis). We did this study to investigate the efficacy and safety of cyclophosphamide as adjuvant therapy for post TB arachnoiditis refractory to corticosteroids and anti-tubercular therapy (ATT). METHODS This was a retrospective case series of patients of refractory post TB arachnoiditis leading to paraparesis and vision loss who received cyclophosphamide as an adjuvant therapy along with standard ATT and corticosteroids. These patients were treated with intravenous cyclophosphamide (dose 500 mg/m2) once a month for 4 consecutive months after informed written consent and were assessed clinically and radiologically before and after cyclophosphamide therapy. RESULTS We had 4 patients with refractory post TB arachnoiditis of whom three became independently ambulatory. There was significant clinical as well as radiological improvement in all the patients. CONCLUSIONS Cyclophosphamide therapy could be an effective therapy for patients with refractory post TB arachnoiditis. Well-designed randomized controlled studies are essential to study the safety and efficacy of cyclophosphamide in this condition.
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Affiliation(s)
| | | | - Anand Kumar
- Department of Neurology, Banaras Hindu University, Banaras, India
| | - Priyanka Samal
- Department of Neurology, Kalinga Hospitals, Bhubaneswar, India
| | - Ajay Garg
- Department of Neuro-radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Garima Shukla
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - V Y Vishnu
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Mamta Bhushan Singh
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - M V Padma Srivastava
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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Santin M, Escrich C, Majòs C, Llaberia M, Grijota MD, Grau I. Tumor necrosis factor antagonists for paradoxical inflammatory reactions in the central nervous system tuberculosis: Case report and review. Medicine (Baltimore) 2020; 99:e22626. [PMID: 33120751 PMCID: PMC7581161 DOI: 10.1097/md.0000000000022626] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Paradoxical reaction/immune reconstitution inflammatory syndrome is common in patients with central nervous system tuberculosis. Management relies on high-dose corticosteroids and surgery when feasible. PATIENT CONCERN We describe 2 cases of HIV-negative patients with corticosteroid-refractory paradoxical reactions of central nervous system tuberculosis. DIAGNOSES The 2 patients experienced clinical impairment shortly after starting therapy for TB, and magnetic resonance imaging showed the presence of tuberculomas, leading to the diagnosis of a paradoxical reaction. INTERVENTIONS We added infliximab, an anti-tumor necrosis factor (TNF)-alpha monoclonal antibody, to the dexamethasone. OUTCOMES Both patients had favorable outcomes, 1 achieving full recovery but 1 suffering neurologic sequelae. LESSONS Clinicians should be aware of the risk of paradoxical reactions/immune reconstitution inflammatory syndrome when treating patients with tuberculosis of the central nervous system and should consider the prompt anti-TNF-α agents in cases not responding to corticosteroids.
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Affiliation(s)
- Miguel Santin
- Tuberculosis Unit, Service of Infectious Diseases, Bellvitge University Hospital-Bellvitge Institute for Biomedical Research (IDIBELL)
- Department of Clinical Sciences, University of Barcelona; L’Hospitalet de Llobregat
| | - Cristina Escrich
- Service of Internal Medicine, Hospital Verge de la Cinta; Tortosa
| | - Carles Majòs
- Department of Neuroradiology, Bellvitge University Hospital-Bellvitge Institute for Biomedical Research (IDIBELL)
| | - Mariona Llaberia
- Service of Infectious Diseases, Bellvitge University Hospital-Bellvitge Institute for Biomedical Research (IDIBELL), Spain
| | - Maria D. Grijota
- Tuberculosis Unit, Service of Infectious Diseases, Bellvitge University Hospital-Bellvitge Institute for Biomedical Research (IDIBELL)
| | - Imma Grau
- Department of Clinical Sciences, University of Barcelona; L’Hospitalet de Llobregat
- Service of Infectious Diseases, Bellvitge University Hospital-Bellvitge Institute for Biomedical Research (IDIBELL), Spain
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Potential anti-TB investigational compounds and drugs with repurposing potential in TB therapy: a conspectus. Appl Microbiol Biotechnol 2020; 104:5633-5662. [PMID: 32372202 DOI: 10.1007/s00253-020-10606-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 03/27/2020] [Accepted: 04/05/2020] [Indexed: 02/07/2023]
Abstract
The latest WHO report estimates about 1.6 million global deaths annually from TB, which is further exacerbated by drug-resistant (DR) TB and comorbidities with diabetes and HIV. Exiguous dosing, incomplete treatment course, and the ability of the tuberculosis bacilli to tolerate and survive current first-line and second-line anti-TB drugs, in either their latent state or active state, has resulted in an increased prevalence of multidrug-resistant (MDR), extensively drug-resistant (XDR), and totally drug-resistant TB (TDR-TB). Although a better understanding of the TB microanatomy, genome, transcriptome, proteome, and metabolome, has resulted in the discovery of a few novel promising anti-TB drug targets and diagnostic biomarkers of late, no new anti-TB drug candidates have been approved for routine therapy in over 50 years, with only bedaquiline, delamanid, and pretomanid recently receiving tentative regulatory approval. Considering this, alternative approaches for identifying possible new anti-TB drug candidates, for effectively eradicating both replicating and non-replicating Mycobacterium tuberculosis, are still urgently required. Subsequently, several antibiotic and non-antibiotic drugs with known treatment indications (TB targeted and non-TB targeted) are now being repurposed and/or derivatized as novel antibiotics for possible use in TB therapy. Insights gathered here reveal that more studies focused on drug-drug interactions between licensed and potential lead anti-TB drug candidates need to be prioritized. This write-up encapsulates the most recent findings regarding investigational compounds with promising anti-TB potential and drugs with repurposing potential in TB therapy.
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Kumar R, Kolloli A, Singh P, Vinnard C, Kaplan G, Subbian S. Thalidomide and Phosphodiesterase 4 Inhibitors as Host Directed Therapeutics for Tuberculous Meningitis: Insights From the Rabbit Model. Front Cell Infect Microbiol 2020; 9:450. [PMID: 32010638 PMCID: PMC6972508 DOI: 10.3389/fcimb.2019.00450] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 12/12/2019] [Indexed: 01/15/2023] Open
Abstract
Tuberculous meningitis (TBM) is the most devastating form of extrapulmonary Mycobacterium tuberculosis infection in humans. Severe inflammation and extensive tissue damage drive the morbidity and mortality of this manifestation of tuberculosis (TB). Antibiotic treatment is ineffective at curing TBM due to variable and incomplete drug penetration across the blood-brain barrier (BBB) and blood-cerebrospinal fluid (CSF) barriers. Adjunctive corticosteroid therapy, used to dampen the inflammation, and the pathologic manifestation of TBM, improves overall survival but does not entirely prevent the morbidity of the disease and has significant toxicities, including immune-suppression. The rabbit has served as a fit for purpose experimental model of human TBM since the early 1900s due to the similarity in the developmental processes of the brain, including neuronal development, myelination, and microglial functions between humans and rabbits. Consistent with the observations made in humans, proinflammatory cytokines, including TNF-α, play a critical role in the pathogenesis of TBM in rabbits focusing the attention on the utility of TNF-α inhibitors in treating the disease. Thalidomide, an inhibitor of monocyte-derived TNF-α, was evaluated in the rabbit model of TBM and shown to improve survival and reduce inflammation of the brain and the meninges. Clinical studies in humans have also shown a beneficial response to thalidomide. However, the teratogenicity and T-cell activation function of the drug limit the use of thalidomide in the clinic. Thus, new drugs with more selective anti-inflammatory properties and a better safety profile are being developed. Some of these candidate drugs, such as phosphodiesterase-4 inhibitors, have been shown to reduce the morbidity and increase the survival of rabbits with TBM. Future studies are needed to assess the beneficial effects of these drugs for their potential to improve the current treatment strategy for TBM in humans.
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Affiliation(s)
- Ranjeet Kumar
- New Jersey Medical School, Rutgers, Public Health Research Institute, The State University of New Jersey, Newark, NJ, United States
| | - Afsal Kolloli
- New Jersey Medical School, Rutgers, Public Health Research Institute, The State University of New Jersey, Newark, NJ, United States
| | - Pooja Singh
- New Jersey Medical School, Rutgers, Public Health Research Institute, The State University of New Jersey, Newark, NJ, United States
| | - Christopher Vinnard
- New Jersey Medical School, Rutgers, Public Health Research Institute, The State University of New Jersey, Newark, NJ, United States
| | - Gilla Kaplan
- University of Cape Town, Cape Town, South Africa
| | - Selvakumar Subbian
- New Jersey Medical School, Rutgers, Public Health Research Institute, The State University of New Jersey, Newark, NJ, United States
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Suárez I, Gruell H, Heyckendorf J, Fünger S, Lichtenstein T, Jung N, Lehmann C, Unnewehr M, Fätkenheuer G, Lange C, Rybniker J. Intensified adjunctive corticosteroid therapy for CNS tuberculomas. Infection 2020; 48:289-293. [PMID: 31900872 DOI: 10.1007/s15010-019-01378-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 11/11/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Central nervous system (CNS) tuberculomas are a challenging manifestation of extrapulmonary tuberculosis often leading to neurological complications and post-treatment sequelae. The role of adjunctive corticosteroid treatment is not fully understood. Most guidelines on management of tuberculosis do not distinguish between tuberculous meningitis and CNS tuberculomas in terms of corticosteroid therapy. METHODS We describe five patients with CNS tuberculomas who required intensified dexamethasone treatment for several months, in two cases up to 18 months. RESULTS These patients were initially treated with the standard four-drug tuberculosis regimen and adjuvant dexamethasone. Neurological symptoms improved rapidly. However, multiple attempts to reduce or discontinue corticosteroids according to guideline recommendations led to clinical deterioration with generalized seizures or new CNS lesions. Thus, duration of adjunctive corticosteroid therapy was extended eventually leading to clinical cure and resolution of lesions. CONCLUSION In contrast to tuberculous meningitis, the treatment for CNS tuberculomas appears to require a prolonged administration of corticosteroids. These findings need to be verified in controlled clinical studies.
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Affiliation(s)
- Isabelle Suárez
- Division of Infectious Diseases, Department I of Internal Medicine, University of Cologne, Cologne, Germany.,German Center for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Henning Gruell
- German Center for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany.,Institute of Virology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50931, Cologne, Germany
| | - Jan Heyckendorf
- Research Center Borstel, Clinical Infectious Diseases, Borstel, Germany.,Partner site Hamburg-Lübeck-Borstel, German Center for Infection Research (DZIF), Borstel, Germany.,International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany
| | - Sarah Fünger
- Division of Infectious Diseases, Department I of Internal Medicine, University of Cologne, Cologne, Germany
| | - Thorsten Lichtenstein
- Faculty of Medicine and University Hospital of Cologne, Institute of Diagnostic and Interventional Radiology, University of Cologne, Cologne, Germany
| | - Norma Jung
- Division of Infectious Diseases, Department I of Internal Medicine, University of Cologne, Cologne, Germany
| | - Clara Lehmann
- Division of Infectious Diseases, Department I of Internal Medicine, University of Cologne, Cologne, Germany.,German Center for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany.,Center for Molecular Medicine Cologne, University of Cologne, 50931, Cologne, Germany
| | - Markus Unnewehr
- Department of Respiratory Medicine and Infectious Diseases, St. Barbara-Klinik, Hamm, Germany.,University of Witten-Herdecke, Witten, Germany
| | - Gerd Fätkenheuer
- Division of Infectious Diseases, Department I of Internal Medicine, University of Cologne, Cologne, Germany.,German Center for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Christoph Lange
- Research Center Borstel, Clinical Infectious Diseases, Borstel, Germany.,Partner site Hamburg-Lübeck-Borstel, German Center for Infection Research (DZIF), Borstel, Germany.,Department of Internal Medicine, Karolinska Institute, Stockholm, Sweden.,International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany
| | - Jan Rybniker
- Division of Infectious Diseases, Department I of Internal Medicine, University of Cologne, Cologne, Germany. .,German Center for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany. .,Center for Molecular Medicine Cologne, University of Cologne, 50931, Cologne, Germany.
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