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Poh XY, Hong JM, Bai C, Miow QH, Thong PM, Wang Y, Rajarethinam R, Ding CSL, Ong CWM. Nos2−/− mice infected with M. tuberculosis develop neurobehavioral changes and immunopathology mimicking human central nervous system tuberculosis. J Neuroinflammation 2022; 19:21. [PMID: 35073927 PMCID: PMC8787888 DOI: 10.1186/s12974-022-02387-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 01/14/2022] [Indexed: 01/31/2023] Open
Abstract
Background Understanding the pathophysiology of central nervous system tuberculosis (CNS-TB) is hampered by the lack of a good pre-clinical model that mirrors the human CNS-TB infection. We developed a murine CNS-TB model that demonstrates neurobehavioral changes with similar immunopathology with human CNS-TB. Methods We injected two Mycobacterium tuberculosis (M.tb) strains, H37Rv and CDC1551, respectively, into two mouse strains, C3HeB/FeJ and Nos2−/− mice, either into the third ventricle or intravenous. We compared the neurological symptoms, histopathological changes and levels of adhesion molecules, chemokines, and inflammatory cytokines in the brain induced by the infections through different routes in different strains. Results Intra-cerebroventricular infection of Nos2−/− mice with M.tb led to development of neurological signs and more severe brain granulomas compared to C3HeB/FeJ mice. Compared with CDC1551 M.tb, H37Rv M.tb infection resulted in a higher neurobehavioral score and earlier mortality. Intra-cerebroventricular infection caused necrotic neutrophil-dominated pyogranulomas in the brain relative to intravenous infection which resulted in disseminated granulomas and mycobacteraemia. Histologically, intra-cerebroventricular infection of Nos2−/− mice with M.tb resembled human CNS-TB brain biopsy specimens. H37Rv intra-cerebroventricular infected mice demonstrated higher brain concentrations of inflammatory cytokines, chemokines and adhesion molecule ICAM-1 than H37Rv intravenous-infected mice. Conclusions Intra-cerebroventricular infection of Nos2−/− mice with H37Rv creates a murine CNS-TB model that resembled human CNS-TB immunopathology, exhibiting the worst neurobehavioral score with a high and early mortality reflecting disease severity and its associated neurological morbidity. Our murine CNS-TB model serves as a pre-clinical platform to dissect host–pathogen interactions and evaluate therapeutic agents for CNS-TB. Supplementary Information The online version contains supplementary material available at 10.1186/s12974-022-02387-0.
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Predictors of Infarction in Tuberculous Meningitis in Indian Patients. J Stroke Cerebrovasc Dis 2021; 30:106088. [PMID: 34536810 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 08/02/2021] [Accepted: 08/29/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Stroke is a devastating complication of tuberculous meningitis (TBM) and is an important determinant of its outcome. We propose a model which would help to predict development of infarction or cerebrovascular events in patients of TBM. METHODS A prospective study with n=129 patients of TBM were evaluated for predictors and outcomes of stroke. A diagnostic grid was formulated with clinical, laboratory and radiology as parameters to predict the vascular outcomes. All patients were followed up for mortality and disability on the basis of modified rankin score (mRS). MRI & CSF cytokines TNF-alpha, IFN- gamma & IL-6,8, 10 were measured at baseline and 3 months. The diagnosis of TBM included definite, probable & possible types and stage I & II with early and late onset of symptoms respectively. RESULTS The mortality was 16.2% and 19.4% of all patients developed stroke. The mean GCS, barthel index and mRS at admission was 57.03± 9.5,10.2±2.3 & 3.3±0.03 respectively mild to moderate infection and functional limitation. Barthel index (BI) happened to be a strong predictor [F=32.6, p=0.001, t=15.5, βeta coefficient =0.002] followed by biomarker TNF-α [F=18.9, p=0.02, t= -2.07, βeta coefficient=-0.04]. N=25 patients developed stroke with TNF-α, IL-6, IFN -γ showing statistically significant increase in all the stroke affected TBM (95% CI; 4.5 to 1.2; p=0.003). At 3 months, it was observed that mRS was statistically significant between stage I & II (95% CI; 5.4 to 2.1; p=0.04). CONCLUSIONS Our data revealed that 19.4% patients developed vascular events during the hospital stay or follow up. We recruited late onset TBM as compared to early onset. BI, TNF-α, IL6 are most potent predictors of stroke post TBM.
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Lee-Rodriguez C, Wada PY, Hung YY, Skarbinski J. Association of Mortality and Years of Potential Life Lost With Active Tuberculosis in the United States. JAMA Netw Open 2020; 3:e2014481. [PMID: 32965497 PMCID: PMC7512053 DOI: 10.1001/jamanetworkopen.2020.14481] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
IMPORTANCE Active tuberculosis (TB) disease leads to substantial mortality but is preventable through screening and treatment for latent TB infection. Early mortality after TB diagnosis (≤1 year) is well described, but delayed mortality (>1 year) among patients with active TB is poorly understood. OBJECTIVE To compare early and delayed mortality and years of potential life (YPL) lost among patients with active TB disease vs an age-, sex-, and year of diagnosis-matched comparison cohort without active TB disease. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study, conducted in the integrated health system of Kaiser Permanente Northern California, included patients with microbiologically confirmed active TB disease from January 1, 1997, to December 31, 2017, and a control cohort matched by age, sex, and year of diagnosis. Multivariable models were used to adjust for demographic and clinical characteristics. Patients with active TB disease prior to 1997 were excluded. Data were analyzed from January 1, 2019, to January 31, 2020. EXPOSURE Microbiologically confirmed TB disease. MAIN OUTCOMES AND MEASURES Early (≤1 year after TB diagnosis) and delayed (>1 year after TB diagnosis) all-cause mortality. RESULTS A total of 2522 patients who had active TB from 1997 to 2017 were identified, with 17 166 person-years of follow-up. The comparison cohort included 100 880 persons with 735 726 person-years of follow-up. In the active TB and comparison cohorts, similar percentages of persons were male (56.3% vs 55.6%), aged 45 to 64 years (33.7% vs 33.7%), and aged 65 years or older (24.7% vs 24.7%). Both early mortality (7.0%) and delayed mortality (16.3%) were higher among patients with active TB disease compared with those without active TB disease (1.1% and 12.0%, respectively). Patients with active TB disease had a significantly higher risk for early (adjusted hazard ratio [aHR], 7.29; 95% CI, 6.08-8.73) and delayed (aHR, 1.78; 95% CI, 1.61-1.98) mortality compared with the comparison cohort (P < .001). Active TB disease was associated with an adjusted -7.0 (95% CI, -8.4 to -5.5) YPL lost compared with the comparison cohort. CONCLUSIONS AND RELEVANCE In this study, patients with active TB disease had significantly higher early and delayed all-cause mortality when adjusting for demographic and clinical characteristics. These findings suggest that TB prevention through screening and treatment of latent TB infection could reduce mortality and YPL lost due to active TB disease.
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Affiliation(s)
- Christian Lee-Rodriguez
- Internal Medicine Residency Program, Oakland Medical Center, Kaiser Permanente Northern California, Oakland
| | - Paul Y. Wada
- Internal Medicine Residency Program, Oakland Medical Center, Kaiser Permanente Northern California, Oakland
| | - Yun-Yi Hung
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Jacek Skarbinski
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Infectious Diseases, Oakland Medical Center, Kaiser Permanente Northern California, Oakland
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Sibandze DB, Magazi BT, Malinga LA, Maningi NE, Shey BA, Pasipanodya JG, Mbelle NN. Machine learning reveals that Mycobacterium tuberculosis genotypes and anatomic disease site impacts drug resistance and disease transmission among patients with proven extra-pulmonary tuberculosis. BMC Infect Dis 2020; 20:556. [PMID: 32736602 PMCID: PMC7393820 DOI: 10.1186/s12879-020-05256-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 07/14/2020] [Indexed: 11/10/2022] Open
Abstract
Background There is a general dearth of information on extrapulmonary tuberculosis (EPTB). Here, we investigated Mycobacterium tuberculosis (Mtb) drug resistance and transmission patterns in EPTB patients treated in the Tshwane metropolitan area, in South Africa. Methods Consecutive Mtb culture-positive non-pulmonary samples from unique EPTB patients underwent mycobacterial genotyping and were assigned to phylogenetic lineages and transmission clusters based on spoligotypes. MTBDRplus assay was used to search mutations for isoniazid and rifampin resistance. Machine learning algorithms were used to identify clinically meaningful patterns in data. We computed odds ratio (OR), attributable risk (AR) and corresponding 95% confidence intervals (CI). Results Of the 70 isolates examined, the largest cluster comprised 25 (36%) Mtb strains that belonged to the East Asian lineage. East Asian lineage was significantly more likely to occur within chains of transmission when compared to the Euro-American and East-African Indian lineages: OR = 10.11 (95% CI: 1.56–116). Lymphadenitis, meningitis and cutaneous TB, were significantly more likely to be associated with drug resistance: OR = 12.69 (95% CI: 1.82–141.60) and AR = 0.25 (95% CI: 0.06–0.43) when compared with other EPTB sites, which suggests that poor rifampin penetration might be a contributing factor. Conclusions The majority of Mtb strains circulating in the Tshwane metropolis belongs to East Asian, Euro-American and East-African Indian lineages. Each of these are likely to be clustered, suggesting on-going EPTB transmission. Since 25% of the drug resistance was attributable to sanctuary EPTB sites notorious for poor rifampin penetration, we hypothesize that poor anti-tuberculosis drug dosing might have a role in the development of resistance.
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Affiliation(s)
- Doctor B Sibandze
- Department of Medical Microbiology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Arcadia, Pretoria, 0007, South Africa.,National Tuberculosis Control Program, Ministry of Health, Manzini, Kingdom of Eswatini
| | - Beki T Magazi
- Department of Medical Microbiology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Arcadia, Pretoria, 0007, South Africa.,Tshwane Division, National Health Laboratory Services, Pretoria, South Africa
| | - Lesibana A Malinga
- Department of Medical Microbiology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Arcadia, Pretoria, 0007, South Africa.,Tuberculosis Platform, South African Medical Research Council, Pretoria, South Africa
| | - Nontuthuko E Maningi
- Department of Medical Microbiology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Arcadia, Pretoria, 0007, South Africa
| | - Bong-Akee Shey
- Department of Medical Microbiology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Arcadia, Pretoria, 0007, South Africa
| | - Jotam G Pasipanodya
- Center For Infectious Diseases Research and Experimental Therapeutics, Texas Tech University Health Sciences Center, 5920 Forest Park Road, Dallas, TX, 75235, USA. .,Praedicare Laboratories, 14830 Venture Drive, Dallas, TX, 75234, USA.
| | - Nontombi N Mbelle
- Department of Medical Microbiology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Arcadia, Pretoria, 0007, South Africa.,Tshwane Division, National Health Laboratory Services, Pretoria, South Africa
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Pasipanodya JG, Smythe W, Merle CS, Olliaro PL, Deshpande D, Magombedze G, McIlleron H, Gumbo T. Artificial intelligence-derived 3-Way Concentration-dependent Antagonism of Gatifloxacin, Pyrazinamide, and Rifampicin During Treatment of Pulmonary Tuberculosis. Clin Infect Dis 2018; 67:S284-S292. [PMID: 30496458 PMCID: PMC6904294 DOI: 10.1093/cid/ciy610] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Background In the experimental arm of the OFLOTUB trial, gatifloxacin replaced ethambutol in the standard 4-month regimen for drug-susceptible pulmonary tuberculosis. The study included a nested pharmacokinetic (PK) study. We sought to determine if PK variability played a role in patient outcomes. Methods Patients recruited in the trial were followed for 24 months, and relapse ascertained using spoligotyping. Blood was drawn for drug concentrations on 2 separate days during the first 2 months of therapy, and compartmental PK analyses was performed. Failure to attain sustained sputum culture conversion at the end of treatment, relapse, or death during follow-up defined therapy failure. In addition to standard statistical analyses, we utilized an ensemble of machine-learning methods to identify patterns and predictors of therapy failure from among 27 clinical and laboratory features. Results Of 126 patients, 95 (75%) had favorable outcomes and 19 (15%) failed therapy, relapsed, or died. Pyrazinamide and rifampicin peak concentrations and area under the concentration-time curves (AUCs) were ranked higher (more important) than gatifloxacin AUCs. The distribution of individual drug concentrations and their ranking varied significantly between South African and West African trial sites; however, drug concentrations still accounted for 31% and 75% of variance of outcomes, respectively. We identified a 3-way antagonistic interaction of pyrazinamide, gatifloxacin, and rifampicin concentrations. These negative interactions disappeared if rifampicin peak concentration was above 7 mg/L. Conclusions Concentration-dependent antagonism contributed to death, relapse, and therapy failure but was abrogated by high rifampicin concentrations. Therefore, increasing both rifampin and gatifloxacin doses could improve outcomes. Clinical Trials Registration NCT00216385.
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Affiliation(s)
- Jotam G Pasipanodya
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Wynand Smythe
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, South Africa
| | - Corinne S Merle
- Faculty of Epidemiology and Population Health, Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, United Kingdom
- Special Programme on Research and Training in Tropical Diseases, World Health Organization, Geneva, Switzerland
| | - Piero L Olliaro
- Special Programme on Research and Training in Tropical Diseases, World Health Organization, Geneva, Switzerland
| | - Devyani Deshpande
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Gesham Magombedze
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, South Africa
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
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Deshpande D, Pasipanodya JG, Mpagama SG, Srivastava S, Bendet P, Koeuth T, Lee PS, Heysell SK, Gumbo T. Ethionamide Pharmacokinetics/Pharmacodynamics-derived Dose, the Role of MICs in Clinical Outcome, and the Resistance Arrow of Time in Multidrug-resistant Tuberculosis. Clin Infect Dis 2018; 67:S317-S326. [PMID: 30496457 PMCID: PMC6260165 DOI: 10.1093/cid/ciy609] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Background Ethionamide is used to treat multidrug-resistant tuberculosis (MDR-TB). The antimicrobial pharmacokinetics/pharmacodynamics, the contribution of ethionamide to the multidrug regimen, and events that lead to acquired drug resistance (ADR) are unclear. Methods We performed a multidose hollow fiber system model of tuberculosis (HFS-TB) study to identify the 0-24 hour area under the concentration-time curve (AUC0-24) to minimum inhibitory concentration (MIC) ratios that achieved maximal kill and ADR suppression, defined as target exposures. Ethionamide-resistant isolates underwent whole-genome and targeted Sanger sequencing. We utilized Monte Carlo experiments (MCEs) to identify ethionamide doses that would achieve the target exposures in 10000 patients with pulmonary tuberculosis. We also identified predictors of time-to-sputum conversion in Tanzanian patients on ethionamide- and levofloxacin-based regimens using multivariate adaptive regression splines (MARS). Results An AUC0-24/MIC >56.2 was identified as the target exposure in the HFS-TB. Early efflux pump induction to ethionamide monotherapy led to simultaneous ethambutol and isoniazid ADR, which abrogated microbial kill of an isoniazid-ethambutol-ethionamide regimen. Genome sequencing of isolates that arose during ethionamide monotherapy revealed mutations in both ethA and embA. In MCEs, 20 mg/kg/day achieved the AUC0-24/MIC >56.2 in >95% of patients, provided the Sensititre assay MIC was <2.5 mg/L. In the clinic, MARS revealed that ethionamide Sensititre MIC had linear negative relationships with time-to-sputum conversion until an MIC of 2.5 mg/L, above which patients with MDR-TB failed combination therapy. Conclusions Ethionamide is an important contributor to MDR-TB treatment regimens, at Sensititre MIC <2.5 mg/L. Suboptimal ethionamide exposures led to efflux pump-mediated ADR.
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Affiliation(s)
- Devyani Deshpande
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Jotam G Pasipanodya
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | | | - Shashikant Srivastava
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Paula Bendet
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Thearith Koeuth
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Pooi S Lee
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Scott K Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
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Mburu JW, Kingwara L, Ester M, Andrew N. Use of classification and regression tree (CART), to identify hemoglobin A1C (HbA 1C) cut-off thresholds predictive of poor tuberculosis treatment outcomes and associated risk factors. J Clin Tuberc Other Mycobact Dis 2018; 11:10-16. [PMID: 31720385 PMCID: PMC6830151 DOI: 10.1016/j.jctube.2018.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 01/18/2018] [Accepted: 01/23/2018] [Indexed: 11/23/2022] Open
Abstract
Background Rifampin-based therapy potentially exacerbates glycemic control among TB patients who are already at high risk of hyperglycemia. This impacts negatively to the optimal care of TB- diabetes mellitus co-affected patients. Classification and regression tree (CART), a machine-learning algorithm impervious to statistical assumptions is one of the ideal tools for clinical decision-making that can be used to identify hemoglobin A1C (HbA1C) cut-off thresholds predictive of poor TB treatment outcomes in such populations. Methods 340TB smear positive patients attending two peri-urban clinics were recruited and prospectively followed up for six months. Baseline HbA1C and random blood glucose (RBG) levels were determined. CART was then used to identify cut-off thresholds and rank outcome predictors at end of therapy by determining Risk ratios (RR) and 95% confidence interval (CI) of each predictor threshold. Fractal geometry law explained effect of weight, while U-shaped curve explained effect of HbA1C on these clinical outcomes. Results Of the 340 patients enrolled: 84%were cured, 7% completed therapy and 9% had unfavorable outcomes out of which 4% (n = 32) had microbiologic failure. Using CART HbA1C identified thresholds were >2.95%, 2.95–4.55% and >4.55%, containing 8/11 (73%), 111/114 (97%) and 189/215 (88%) of patients who experienced favorable outcomes. RR for favorable outcome in patients with weight <53.25 Kg compared to >53.25 Kg was 0.61 (95% CI, 0.45–0.88) among patients with HbA1C >4.55%. Simulation of the CART model with 13 patients data failed therapy revealed that 8/11 (73%) of patients with HbA1C <2.95%, 111/114 (97%) with HbA1C between 2.95% and 4.55% and 189/215 (88%) of patients with HbA1c >4.55% experienced microbiologic failure. Conclusion Using fractal geometry relationships to drug pharmacokinetics, low weight has profound influence on failure of anti-tuberculosis treatment among patients at risk for diabetes mellitus.
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Affiliation(s)
- Josephine W Mburu
- National Reference Tuberculosis Laboratory, MOH, Kenya.,Jomo Kenyatta University of Agriculture and Technology (JKUAT), Kenya
| | | | - Magiri Ester
- Jomo Kenyatta University of Agriculture and Technology (JKUAT), Kenya
| | - Nyerere Andrew
- Jomo Kenyatta University of Agriculture and Technology (JKUAT), Kenya
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Srivastava S, Deshpande D, Pasipanodya J, Nuermberger E, Swaminathan S, Gumbo T. Optimal Clinical Doses of Faropenem, Linezolid, and Moxifloxacin in Children With Disseminated Tuberculosis: Goldilocks. Clin Infect Dis 2017; 63:S102-S109. [PMID: 27742641 PMCID: PMC5064158 DOI: 10.1093/cid/ciw483] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background. When treated with the same antibiotic dose, children achieve different 0- to 24-hour area under the concentration-time curves (AUC0–24) because of maturation and between-child physiological variability on drug clearance. Children are also infected by Mycobacterium tuberculosis isolates with different antibiotic minimum inhibitory concentrations (MICs). Thus, each child will achieve different AUC0–24/MIC ratios when treated with the same dose. Methods. We used 10 000-subject Monte Carlo experiments to identify the oral doses of linezolid, moxifloxacin, and faropenem that would achieve optimal target exposures associated with optimal efficacy in children with disseminated tuberculosis. The linezolid and moxifloxacin exposure targets were AUC0–24/MIC ratios of 62 and 122, and a faropenem percentage of time above MIC >60%, in combination therapy. A linezolid AUC0–24 of 93.4 mg × hour/L was target for toxicity. Population pharmacokinetic parameters of each drug and between-child variability, as well as MIC distribution, were used, and the cumulative fraction of response (CFR) was calculated. We also considered drug penetration indices into meninges, bone, and peritoneum. Results. The linezolid dose of 15 mg/kg in full-term neonates and infants aged up to 3 months and 10 mg/kg in toddlers, administered once daily, achieved CFR ≥ 90%, with <10% achieving linezolid AUC0–24 associated with toxicity. The moxifloxacin dose of 25 mg/kg/day achieved a CFR > 90% in infants, but the optimal dose was 20 mg/kg/day in older children. The faropenem medoxomil optimal dosage was 30 mg/kg 3–4 times daily. Conclusions. The regimen and doses of linezolid, moxifloxacin, and faropenem identified are proposed to be adequate for all disseminated tuberculosis syndromes, whether drug-resistant or -susceptible.
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Affiliation(s)
- Shashikant Srivastava
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Devyani Deshpande
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Jotam Pasipanodya
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas
| | - Eric Nuermberger
- Center for Tuberculosis Research, Department of Medicine Department of International Health, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas Department of Medicine, University of Cape Town, Observatory, South Africa
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Clinical Features and Outcome in Adult Cases of Tuberculous Meningitis in Tertiary Care Hospital in Antananarivo, Madagascar. BIOMED RESEARCH INTERNATIONAL 2017; 2017:9316589. [PMID: 28396873 PMCID: PMC5371227 DOI: 10.1155/2017/9316589] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Accepted: 03/05/2017] [Indexed: 11/22/2022]
Abstract
Purpose. We aimed to describe and to assess prognosis factors in tuberculous meningitis in adult patients. Methods. We performed a retrospective study of case records of adult patients. Patients classified as definite, probable, or possible tuberculous meningitis according to standardized definition criteria were included and assessed in the study. Results. Seventy-five patients were included in the study. Tuberculous meningitis was classified as definite in 8 (10.7%), probable in 44 (58.7%), and possible in 23 patients (30.6%). HIV was found in 3% of patients. Patients were in advanced stages at admission in 82.7%. Median duration of symptoms prior to admission was 3 weeks (IQR: 2–5). Median time to diagnosis following admission was 5 days (IQR: 3–8). Median CSF WCC was 75 per mm3 with lymphocytic predominance in 38 cases (52.8%). Median CSF glucose level was 1.48 mmol/L and median CSF protein level was 1 g/L. Mortality rate was 28%. Age ≥ 35 years (aOR: 4.06; 95% CI: 1.16–14.26) and coma (aOR: 12.98; 95% CI: 1.13–149.16) predicted inpatient mortality. Conclusion. Most of the patients experienced more than 3 weeks of diagnostic delay prior to admission. Mortality was high and occurred early after admission. Age and coma were identified as independent prognosis factors.
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Pasipanodya JG, Mubanga M, Ntsekhe M, Pandie S, Magazi BT, Gumedze F, Myer L, Gumbo T, Mayosi BM. Tuberculous Pericarditis is Multibacillary and Bacterial Burden Drives High Mortality. EBioMedicine 2015; 2:1634-9. [PMID: 26870789 PMCID: PMC4740299 DOI: 10.1016/j.ebiom.2015.09.034] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 09/16/2015] [Accepted: 09/17/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Tuberculous pericarditis is considered to be a paucibacillary process; the large pericardial fluid accumulation is attributed to an inflammatory response to tuberculoproteins. Mortality rates are high. We investigated the role of clinical and microbial factors predictive of tuberculous pericarditis mortality using the artificial intelligence algorithm termed classification and regression tree (CART) analysis. METHODS Patients were prospectively enrolled and followed in the Investigation of the Management of Pericarditis (IMPI) registry. Clinical and laboratory data of 70 patients with confirmed tuberculous pericarditis, including time-to-positive (TTP) cultures from pericardial fluid, were extracted and analyzed for mortality outcomes using CART. TTP was translated to log10 colony forming units (CFUs) per mL, and compared to that obtained from sputum in some of our patients. FINDINGS Seventy patients with proven tuberculous pericarditis were enrolled. The median patient age was 35 (range: 20-71) years. The median, follow up was for 11.97 (range: 0·03-74.73) months. The median TTP for pericardial fluid cultures was 22 (range: 4-58) days or 3.91(range: 0·5-8·96) log10CFU/mL, which overlapped with the range of 3.24-7.42 log10CFU/mL encountered in sputum, a multi-bacillary disease. The overall mortality rate was 1.43 per 100 person-months. CART identified follow-up duration of 5·23 months on directly observed therapy, a CD4 + count of ≤ 199.5/mL, and TTP ≤ 14 days (bacillary load ≥ 5.53 log10 CFU/mL) as predictive of mortality. TTP interacted with follow-up duration in a non-linear fashion. INTERPRETATION Patients with culture confirmed tuberculous pericarditis have a high bacillary burden, and this bacterial burden drives mortality. Thus proven tuberculosis pericarditis is not a paucibacillary disease. Moreover, the severe immunosuppression suggests limited inflammation. There is a need for the design of a highly bactericidal regimen for this condition.
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Affiliation(s)
- Jotam G. Pasipanodya
- Center for Infectious Diseases Research & Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Mwenya Mubanga
- The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Mpiko Ntsekhe
- The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Shaheen Pandie
- The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Beki T. Magazi
- National Health Laboratory Services (Tshwane Academic Division), Department of Medical Microbiology, University of Pretoria, South Africa
| | - Freedom Gumedze
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Tawanda Gumbo
- The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
- Center for Infectious Diseases Research & Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Bongani M. Mayosi
- The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
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Chen HL, Lu CH, Chang CD, Chen PC, Chen MH, Hsu NW, Chou KH, Lin WM, Lin CP, Lin WC. Structural deficits and cognitive impairment in tuberculous meningitis. BMC Infect Dis 2015. [PMID: 26198732 PMCID: PMC4510907 DOI: 10.1186/s12879-015-1011-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Background Chronic neuropsychological sequelae may occur in patients with tuberculous meningitis (TBM). The impact of structural abnormalities on the clinical performance of patients with TBM is unknown. This study applied the Diffeomorphic Anatomical Registration Through Exponentiated Lie Algebra (DARTEL) voxel-based morphometry (VBM) to determine if gray matter deficits in TBM are associated with acute presentations and chronic cognitive impairment. Methods Seventeen patients with TBM who discontinued their anti-TB therapy for more than six months, and 17 age-, sex-, and education-matched healthy subjects were enrolled. Differences in gray matter volume (GMV) between patients and healthy controls were investigated using DARTEL-VBM to determine structural abnormalities. Disease severity during the acute stage was scored by clinical profiles and conventional imaging findings. Correlations among chronic structural deficits, cognitive impairment, and initial disease severity were assessed. Results The patients with TBM had worse neuropsychological subtest performances than the healthy controls. Compared to the controls, the patients showed smaller GMVs in the right thalamus, right caudate nucleus, right superior and middle temporal gyrus, right precuneus, and left putamen (p < 0.001). The smaller GMVs in the right thalamus, right superior temporal gyrus, right precuneus, left putamen, and right caudate nucleus (p < 0.05) were further associated with worse cognitive function. More severe initial disease also correlated with smaller GMVs in the right caudate nucleus (p < 0.05). Conclusion Multiple domain cognitive impairment may persist in patients with chronic TBM even after appropriate treatment. Worse initial disease severity may contribute to the vulnerability of brain tissue to damage, with subsequent neuropsychological consequences.
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Affiliation(s)
- Hsiu-Ling Chen
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Sung, Kaohsiung, 83305, Taiwan. .,Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan.
| | - Cheng-Hsien Lu
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - Ching-Di Chang
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Sung, Kaohsiung, 83305, Taiwan.
| | - Pei-Chin Chen
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Sung, Kaohsiung, 83305, Taiwan.
| | - Meng-Hsiang Chen
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Sung, Kaohsiung, 83305, Taiwan.
| | - Nai-Wen Hsu
- Department of Radiology, Yuan's General Hospital, Kaohsiung, Taiwan.
| | - Kun-Hsien Chou
- Institute of Neuroscience, National Yang-Ming University, Taipei, Taiwan.
| | - Wei-Ming Lin
- Department of Diagnostic Radiology, Chang Gung Memorial Hospital at Chiayi, Chang Gung University College of Medicine, Chiayi, Taiwan.
| | - Ching-Po Lin
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan. .,Institute of Neuroscience, National Yang-Ming University, Taipei, Taiwan.
| | - Wei-Che Lin
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Sung, Kaohsiung, 83305, Taiwan.
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12
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Miller TL, Wilson FA, Pang JW, Beavers S, Hoger S, Sharnprapai S, Pagaoa M, Katz DJ, Weis SE. Mortality hazard and survival after tuberculosis treatment. Am J Public Health 2015; 105:930-7. [PMID: 25790407 PMCID: PMC4386531 DOI: 10.2105/ajph.2014.302431] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2014] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We compared mortality among tuberculosis (TB) survivors and a similar population. METHODS We used local health authority records from 3 US sites to identify 3853 persons who completed adequate treatment of TB and 7282 individuals diagnosed with latent TB infection 1993 to 2002. We then retrospectively observed mortality after 6 to 16 years of observation. We ascertained vital status as of December 31, 2008, using the Centers for Disease Control and Prevention's National Death Index. We analyzed mortality rates, hazards, and associations using Cox regression. RESULTS We traced 11 135 individuals over 119 772 person-years of observation. We found more all-cause deaths (20.7% vs 3.1%) among posttreatment TB patients than among the comparison group, an adjusted average excess of 7.6 deaths per 1000 person-years (8.8 vs 1.2; P < .001). Mortality among posttreatment TB patients varied with observable factors such as race, site of disease, HIV status, and birth country. CONCLUSIONS Fully treated TB is still associated with substantial mortality risk. Cure as currently understood may be insufficient protection against TB-associated mortality in the years after treatment, and TB prevention may be a valuable opportunity to modify this risk.
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Affiliation(s)
- Thaddeus L Miller
- Thaddeus L. Miller is with the Department of Health Management and Policy, University of North Texas Health Science Center, Fort Worth. Stephen E. Weis is with the Department of Medicine, University of North Texas Health Science Center. Fernando A. Wilson is with the Department of Health Services Research & Administration, University of Nebraska Medical Center, Omaha. Jenny W. Pang is with the Department of Epidemiology, University of Washington School of Public Health, Seattle. Suzanne Beavers, Melissa Pagaoa, and Dolly J. Katz are with the Centers for Disease Control and Prevention, Atlanta, GA. Sally Hoger is with the Department of Medical Laboratory Sciences, Tarleton State University, Fort Worth, TX. Sharon Sharnprapai is with the Massachusetts Department of Public Health, Boston
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Mulero Carrillo P, Pedraza Hueso M, Rojo Martínez E, Guerrero Peral Á. Meningovascular tuberculosis: Case study of an atypical presentation. NEUROLOGÍA (ENGLISH EDITION) 2014. [DOI: 10.1016/j.nrleng.2012.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Peng T, Zhou Y, Li J, Li J, Wan W, Jia Y. Detection of Delta-like 1 ligand for the diagnosis of tuberculous meningitis: An effective and rapid diagnostic method. J Int Med Res 2014; 42:728-36. [PMID: 24651996 DOI: 10.1177/0300060513498669] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 06/16/2013] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To investigate the diagnostic value of Delta-like 1 ligand (DLL1) in cerebrospinal fluid (CSF) and serum, in tuberculous meningitis (TBM). METHODS Patients with a definite diagnosis of central nervous system infection (TBM, viral meningitis/encephalitis or bacterial meningitis) were prospectively enrolled alongside patients with intracranial metastatic tumour and patients with no diagnosis (who served as controls). DLL1 content in CSF and serum was measured quantitatively by enzyme-linked immunosorbent assay; analyses were blinded. RESULTS A total of 173 patients were enrolled: 62 with TBM; 38 with viral meningitis/encephalitis; 26 with bacterial meningitis; 17 with intracranial metastatic tumour; 30 with no diagnosis. CSF DLL1 content was highest for TBM; there were no differences in CSF DLL1 between the other groups. Serum DLL1 content was highest for the TBM and intracranial metastatic tumour groups, with significant differences between the TBM group and the viral meningitis/encephalitis, bacterial meningitis and nondiagnosed groups. There were no differences in serum DLL1 between the viral meningitis/encephalitis, bacterial meningitis and nondiagnosed groups, or between the TBM group and the tumour group. CONCLUSION As a new biomarker, DLL1 may be of great clinical importance in the diagnosis of TBM.
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Affiliation(s)
- Tao Peng
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yan Zhou
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jinyi Li
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jinghong Li
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wencui Wan
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yanjie Jia
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Pusch T, Pasipanodya JG, Hall RG, Gumbo T. Therapy duration and long-term outcomes in extra-pulmonary tuberculosis. BMC Infect Dis 2014; 14:115. [PMID: 24580808 PMCID: PMC3943436 DOI: 10.1186/1471-2334-14-115] [Citation(s) in RCA: 13] [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: 08/08/2013] [Accepted: 02/18/2014] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Tuberculosis is classified as either pulmonary or extra-pulmonary (EPTB). While much focus has been paid to pulmonary tuberculosis, EPTB has received scant attention. Moreover, EPTB is viewed as one wastebasket diagnosis, as "the other" which is not pulmonary. METHODS This is a retrospective cohort study of all patients treated for EPTB in the state of Texas between January 2000 and December 2005, who had no pulmonary disease. Clinical and epidemiological factors were abstracted from electronic records of the Report of Verified Case of Tuberculosis. The long-term outcome, which is death by December 2011, was established using the Social Security Administration Death Master File database. Survival in EPTB patients was compared to those with latent tuberculosis, as well as between different types of EPTB, using Cox proportional hazard models. A hybrid of the machine learning method of classification and regression tree analyses and standard regression models was used to identify high-order interactions and clinical factors predictive of long-term all-cause mortality. RESULTS Four hundred and thirty eight patients met study criteria; the median study follow-up period for the cohort was 7.8 (inter-quartile range 6.0-10.1) years. The overall all-cause mortality rate was 0.025 (95% confidence interval [CI]: 0.021-0.030) per 100 person-year of follow-up. The significant predictors of poor long-term outcome were age (hazard ratio [HR] for each year of age-at-diagnosis was 1.05 [CI: 1.04-1.06], treatment duration, type of EPTB and HIV-infection (HR = 2.16; CI: 1.22, 3.83). Mortality in genitourinary tuberculosis was no different from latent tuberculosis, while meningitis had the poorest long-term outcome of 46.2%. Compared to meningitis the HR for death was 0.50 (CI: 0.27-0.91) for lymphatic disease, 0.42 (CI: 0.21-0.81) for bone/joint disease, and 0.59 (CI: 0.27-1.31) for peritonitis. The relationship between mortality and therapy duration for each type of EPTB was a unique "V" shaped curve, with the lowest mortality observed at different therapy durations for each, beyond which mortality increased. CONCLUSIONS EPTB is comprised of several different diseases with different outcomes and durations of therapy. The "V" shaped relationship between therapy duration and outcome leads to the hypothesis that longer duration of therapy may lead to higher patient mortality.
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Affiliation(s)
- Tobias Pusch
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, USA
| | - Jotam G Pasipanodya
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, USA
- Office of Global Health, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, Texas 75390-8504, USA
| | - Ronald G Hall
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center, School of Pharmacy, 4500 Lancaster, Dallas, Texas 75216, USA
| | - Tawanda Gumbo
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, USA
- Office of Global Health, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, Texas 75390-8504, USA
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Mulero Carrillo P, Pedraza Hueso MI, Rojo Martínez E, Guerrero Peral ÁL. Meningovascular tuberculosis: case study of an atypical presentation. Neurologia 2012; 29:187-9. [PMID: 22981123 DOI: 10.1016/j.nrl.2012.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2012] [Accepted: 07/11/2012] [Indexed: 10/27/2022] Open
Affiliation(s)
- P Mulero Carrillo
- Servicio de Neurología, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - M I Pedraza Hueso
- Servicio de Neurología, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - E Rojo Martínez
- Servicio de Neurología, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - Á L Guerrero Peral
- Servicio de Neurología, Hospital Clínico Universitario de Valladolid, Valladolid, España.
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Mycobacterial shuttle vectors designed for high-level protein expression in infected macrophages. Appl Environ Microbiol 2012; 78:6829-37. [PMID: 22820329 DOI: 10.1128/aem.01674-12] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Mycobacterial shuttle vectors contain dual origins of replication for growth in both Escherichia coli and mycobacteria. One such vector, pSUM36, was re-engineered for high-level protein expression in diverse bacterial species. The modified vector (pSUM-kan-MCS2) enabled green fluorescent protein expression in E. coli, Mycobacterium smegmatis, and M. avium at levels up to 50-fold higher than that detected with the parental vector, which was originally developed with a lacZα promoter. This high-level fluorescent protein expression allowed easy visualization of M. smegmatis and M. avium in infected macrophages. The M. tuberculosis gene esat-6 was cloned in place of the green fluorescence protein gene (gfp) to determine the impact of ESAT-6 on the innate inflammatory response. The modified vector (pSUM-kan-MCS2) yielded high levels of ESAT-6 expression in M. smegmatis. The ability of ESAT-6 to suppress innate inflammatory pathways was assayed with a novel macrophage reporter cell line, designed with an interleukin-6 (IL-6) promoter-driven GFP cassette. This stable cell line fluoresces in response to diverse mycobacterial strains and stimuli, such as lipopolysaccharide. M. smegmatis clones expressing high levels of ESAT-6 failed to attenuate IL-6-driven GFP expression. Pure ESAT-6, produced in E. coli, was insufficient to suppress a strong inflammatory response elicited by M. smegmatis or lipopolysaccharide, with ESAT-6 itself directly activating the IL-6 pathway. In summary, a pSUM-protein expression vector and a mammalian IL-6 reporter cell line provide new tools for understanding the pathogenic mechanisms deployed by various mycobacterial species.
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Christensen ASH, Roed C, Omland LH, Andersen PH, Obel N, Andersen ÅB. Long-term mortality in patients with tuberculous meningitis: a Danish nationwide cohort study. PLoS One 2011; 6:e27900. [PMID: 22132165 PMCID: PMC3222654 DOI: 10.1371/journal.pone.0027900] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Accepted: 10/27/2011] [Indexed: 12/01/2022] Open
Abstract
Background With high short-term mortality and substantial excess morbidity among survivors, tuberculous meningitis (TBM) is the most severe manifestation of extra-pulmonary tuberculosis (TB). The objective of this study was to assess the long-term mortality and causes of death in a TBM patient population compared to the background population. Methods A nationwide cohort study was conducted enrolling patients notified with TBM in Denmark from 1972–2008 and alive one year after TBM diagnosis. Data was extracted from national registries. From the background population we identified a control cohort of individuals matched on gender and date of birth. Kaplan-Meier survival curves and Cox regression analysis were used to estimate mortality rate ratios (MRR) and analyse causes of death. Findings A total of 55 TBM patients and 550 individuals from the background population were included in the study. Eighteen patients (32.7%) and 107 population controls (19.5%) died during the observation period. The overall MRR was 1.79 (95%CI: 1.09–2.95) for TBM patients compared to the population control cohort. TBM patients in the age group 31–60 years at time of diagnosis had the highest relative risk of death (MRR 2.68; 95%CI 1.34–5.34). The TBM patients had a higher risk of death due to infectious disease, but not from other causes of death. Conclusion Adult TBM patients have an almost two-fold increased long-term mortality and the excess mortality stems from infectious disease related causes of death.
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Vecino M, Pasipanodya JG, Slocum P, Bae S, Munguia G, Miller T, Fernandez M, Drewyer G, Weis SE. Evidence for chronic lung impairment in patients treated for pulmonary tuberculosis. J Infect Public Health 2011; 4:244-52. [PMID: 22118719 DOI: 10.1016/j.jiph.2011.08.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Revised: 07/01/2011] [Accepted: 08/02/2011] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Patients with pulmonary tuberculosis are likely to develop pulmonary impairment after tuberculosis (PIAT). The stability of PIAT and the relationship of PIAT to the duration of delay in tuberculosis diagnosis and treatment have not been fully characterized. METHODS We performed serial pulmonary function tests (PFTs) in a cohort treated for pulmonary tuberculosis after 20 weeks of tuberculosis therapy and again on or after treatment completion to determine the stability of PIAT. PFTs were compared with the duration of delay in tuberculosis diagnosis and treatment, as well as other demographic variables. RESULTS The median duration between the first and second tests was 15 (interquartile range 9-34) weeks. The mean change in FVC was -0.02l (95% confidence interval [CI] -0.09, 0.06), and the % predicted was -0.02 (95% CI -2.17, 2.12). FEV1 changes were 0l (95% CI -0.05, 0.06), and the % predicted was -0.11 (95% CI -1.82, 1.60). PIAT was not related to the duration of delay in tuberculosis diagnosis or treatment, age or smoking. CONCLUSIONS PIAT was not associated with the duration of delay in tuberculosis diagnosis and treatment and did not significantly change during follow-up. These data demonstrate that, for many individuals, the completion of tuberculosis treatment is the beginning, not the end, of their tuberculosis illness.
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Affiliation(s)
- Mauricio Vecino
- Department of Medicine, University of North Texas Health Science Center at Fort Worth, TX, United States
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Pasipanodya J, Gumbo T. An oracle: antituberculosis pharmacokinetics-pharmacodynamics, clinical correlation, and clinical trial simulations to predict the future. Antimicrob Agents Chemother 2011; 55:24-34. [PMID: 20937778 PMCID: PMC3019641 DOI: 10.1128/aac.00749-10] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Antimicrobial pharmacokinetic-pharmacodynamic (PK/PD) science and clinical trial simulations have not been adequately applied to the design of doses and dose schedules of antituberculosis regimens because many researchers are skeptical about their clinical applicability. We compared findings of preclinical PK/PD studies of current first-line antituberculosis drugs to findings from several clinical publications that included microbiologic outcome and pharmacokinetic data or had a dose-scheduling design. Without exception, the antimicrobial PK/PD parameters linked to optimal effect were similar in preclinical models and in tuberculosis patients. Thus, exposure-effect relationships derived in the preclinical models can be used in the design of optimal antituberculosis doses, by incorporating population pharmacokinetics of the drugs and MIC distributions in Monte Carlo simulations. When this has been performed, doses and dose schedules of rifampin, isoniazid, pyrazinamide, and moxifloxacin with the potential to shorten antituberculosis therapy have been identified. In addition, different susceptibility breakpoints than those in current use have been identified. These steps outline a more rational approach than that of current methods for designing regimens and predicting outcome so that both new and older antituberculosis agents can shorten therapy duration.
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Affiliation(s)
- Jotam Pasipanodya
- Division of Infectious Diseases, UT Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd., Dallas, Texas 75390-9113
| | - Tawanda Gumbo
- Division of Infectious Diseases, UT Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd., Dallas, Texas 75390-9113
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Garg RK, Sinha MK. Tuberculous meningitis in patients infected with human immunodeficiency virus. J Neurol 2010; 258:3-13. [PMID: 20848123 DOI: 10.1007/s00415-010-5744-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Accepted: 09/01/2010] [Indexed: 12/11/2022]
Abstract
Tuberculosis is the most common opportunistic infection in human immunodeficiency virus (HIV) infected persons. HIV-infected patients have a high incidence of tuberculous meningitis as well. The exact incidence and prevalence of tuberculous meningitis in HIV-infected patients are not known. HIV infection does not significantly alter the clinical manifestations, laboratory, radiographic findings, or the response to therapy. Still, some differences have been noted. For example, the histopathological examination of exudates in HIV-infected patients shows fewer lymphocytes, epithelioid cells, and Langhan's type of giant cells. Larger numbers of acid-fast bacilli may be seen in the cerebral parenchyma and meninges. The chest radiograph is abnormal in up to 46% of patients with tuberculous meningitis. Tuberculous meningitis is likely to present with cerebral infarcts and mass lesions. Cryptococcal meningitis is important in differential diagnosis. The recommended duration of treatment in HIV-infected patients is 9-12 months. The benefit of adjunctive corticosteroids is uncertain. Antiretroviral therapy and antituberculosis treatment should be initiated at the same time, regardless of CD4 cell counts. Tuberculous meningitis may be a manifestation of paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome. Some studies have demonstrated a significant impact of HIV co-infection on mortality from tuberculous meningitis. HIV-infected patients with multidrug-resistant tuberculous meningitis have significantly higher mortality. The best way to prevent HIV-associated tuberculous meningitis is to diagnose and isolate infectious cases of tuberculosis promptly and administer appropriate treatment.
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Affiliation(s)
- Ravindra Kumar Garg
- Department of Neurology, Chhatrapati Shahuji Maharaj Medical University, Lucknow, 226003, Uttar Pradesh, India.
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Gumbo T. New susceptibility breakpoints for first-line antituberculosis drugs based on antimicrobial pharmacokinetic/pharmacodynamic science and population pharmacokinetic variability. Antimicrob Agents Chemother 2010; 54:1484-91. [PMID: 20086150 PMCID: PMC2849358 DOI: 10.1128/aac.01474-09] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2009] [Revised: 12/09/2009] [Accepted: 01/11/2010] [Indexed: 01/22/2023] Open
Abstract
Arguably, one of the most common and consequential laboratory tests performed in the world is Mycobacterium tuberculosis susceptibility testing. M. tuberculosis resistance is defined by growth of > or =1% of a bacillary inoculum on the critical concentration of an antibiotic. The critical concentration was chosen based on inhibition of > or =95% of wild-type isolates. The critical concentration of isoniazid is either 0.2 or 1.0 mg/liter, that of rifampin is 1.0 mg/liter, that of pyrazinamide is 100 mg/liter, that of ethambutol is 5.0 mg/liter, and that of fluoroquinolones is 1.0 mg/liter. However, the relevance of these concentrations to microbiologic and clinical outcomes is unclear. Critical concentrations were identified using the ability to achieve the antibiotic area under the concentration-time curve/MIC ratio associated with > or =90% of maximal kill (EC(90)) of M. tuberculosis in > or =90% of patients. Population pharmacokinetic parameters and their variability encountered in tuberculosis patients were utilized in Monte Carlo simulations to determine the probability that particular daily doses of the drugs would achieve or exceed the EC(90) in the epithelial lining fluid of 10,000 tuberculosis patients. Failure to achieve EC(90) in > or =90% of patients at a particular MIC was defined as drug resistance. The critical concentrations of moxifloxacin and ethambutol remained unchanged, but a critical concentration of 50 mg/liter was identified for pyrazinamide, 0.0312 mg/liter and 0.125 mg/liter were defined for low- and high-level isoniazid resistance, respectively, and 0.0625 mg/liter was defined for rifampin. Thus, current critical concentrations of first-line antituberculosis drugs are overoptimistic and should be set lower. With the proposed breakpoints, the rates of multidrug-resistant tuberculosis could become 4-fold higher than currently assumed.
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Affiliation(s)
- Tawanda Gumbo
- Division of Infectious Diseases, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9113, USA.
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