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Painter H, Harriss E, Fletcher HA, McShane H, Tanner R. Development and application of the direct mycobacterial growth inhibition assay: a systematic review. Front Immunol 2024; 15:1355983. [PMID: 38380319 PMCID: PMC10877019 DOI: 10.3389/fimmu.2024.1355983] [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: 12/14/2023] [Accepted: 01/17/2024] [Indexed: 02/22/2024] Open
Abstract
Introduction First described by Wallis et al. in 2001 for the assessment of TB drugs, the direct mycobacterial growth inhibition assay (MGIA) offers a tractable ex vivo tool measuring the combined influences of host immunity, strain virulence and intervention effects. Over the past 13 years, we have led efforts to adapt the direct MGIA for the assessment of TB vaccines including optimisation, harmonisation and validation of BCG vaccine-induced responses as a benchmark, as well as assay transfer to institutes worldwide. Methods We have performed a systematic review on the primary published literature describing the development and applications of the direct MGIA from 2001 to June 2023 in accordance with the PRISMA reporting guidelines. Results We describe 63 studies in which the direct MGIA has been applied across species for the evaluation of TB drugs and novel TB vaccine candidates, the study of clinical cohorts including those with comorbidities, and to further understanding of potential immune correlates of protection from TB. We provide a comprehensive update on progress of the assay since its conception and critically evaluate current findings and evidence supporting its utility, highlighting priorities for future directions. Discussion While further standardisation and validation work is required, significant advancements have been made in the past two decades. The direct MGIA provides a potentially valuable tool for the early evaluation of TB drug and vaccine candidates, clinical cohorts, and immune mechanisms of mycobacterial control. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42023423491.
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Affiliation(s)
- Hannah Painter
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Eli Harriss
- Bodleian Health Care Libraries, University of Oxford, Oxford, United Kingdom
| | - Helen A. Fletcher
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Helen McShane
- Nuffield Department of Medicine, Jenner Institute, University of Oxford, Oxford, United Kingdom
| | - Rachel Tanner
- Department of Biology, University of Oxford, Oxford, United Kingdom
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Simpson G, Philip M, Vogel JP, Scoullar MJL, Graham SM, Wilson AN. The clinical presentation and detection of tuberculosis during pregnancy and in the postpartum period in low- and middle-income countries: A systematic review and meta-analysis. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002222. [PMID: 37611006 PMCID: PMC10446195 DOI: 10.1371/journal.pgph.0002222] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/10/2023] [Indexed: 08/25/2023]
Abstract
For women infected with Mycobacterium tuberculosis, pregnancy is associated with an increased risk of developing or worsening TB disease. TB in pregnancy increases the risk of adverse maternal and neonatal outcomes, however the detection of TB in pregnancy is challenging. We aimed to identify and summarise the findings of studies regarding the clinical presentation and diagnosis of TB during pregnancy and the postpartum period (within 6 months of birth) in low-and middle-income countries (LMICs). A systematic review was conducted searching Ovid MEDLINE, Embase, CINAHL and Global Index Medicus databases. We included any primary research study of women diagnosed with TB during pregnancy or the postpartum period in LMICs that described the clinical presentation or method of diagnosis. Meta-analysis was used to determine pooled prevalence of TB clinical features and health outcomes, as well as detection method yield. Eighty-seven studies of 2,965 women from 27 countries were included. 70.4% of women were from South Africa or India and 44.7% were known to be HIV positive. For 1,833 women where TB type was reported, pulmonary TB was most common (79.6%). Most studies did not report the prevalence of presenting clinical features. Where reported, the most common were sputum production (73%) and cough (68%). Having a recent TB contact was found in 45% of women. Only six studies screened for TB using diagnostic testing for asymptomatic antenatal women and included mainly HIV-positive women ‒ 58% of women with bacteriologically confirmed TB did not report symptoms and only two were in HIV-negative women. Chest X-ray had the highest screening yield; 60% abnormal results of 3036 women tested. Screening pregnant women for TB-related symptoms and risk factors is important but detection yields are limited. Chest radiography and bacteriological detection methods can improve this, but procedures for optimal utilisation remain uncertain in this at-risk population. Trial registration: Prospero registration number: CRD42020202493.
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Affiliation(s)
- Grace Simpson
- Maternal Child and Adolescent Health Program, International Development, Burnet Institute, Melbourne, Australia
| | - Moira Philip
- Maternal Child and Adolescent Health Program, International Development, Burnet Institute, Melbourne, Australia
| | - Joshua P. Vogel
- Maternal Child and Adolescent Health Program, International Development, Burnet Institute, Melbourne, Australia
| | - Michelle J. L. Scoullar
- Maternal Child and Adolescent Health Program, International Development, Burnet Institute, Melbourne, Australia
| | - Stephen M. Graham
- Maternal Child and Adolescent Health Program, International Development, Burnet Institute, Melbourne, Australia
- Centre for International Health, University of Melbourne Department of Paediatrics, Melbourne, Australia
| | - Alyce N. Wilson
- Maternal Child and Adolescent Health Program, International Development, Burnet Institute, Melbourne, Australia
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Kim H, Choi HG, Shin SJ. Bridging the gaps to overcome major hurdles in the development of next-generation tuberculosis vaccines. Front Immunol 2023; 14:1193058. [PMID: 37638056 PMCID: PMC10451085 DOI: 10.3389/fimmu.2023.1193058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 07/27/2023] [Indexed: 08/29/2023] Open
Abstract
Although tuberculosis (TB) remains one of the leading causes of death from an infectious disease worldwide, the development of vaccines more effective than bacille Calmette-Guérin (BCG), the only licensed TB vaccine, has progressed slowly even in the context of the tremendous global impact of TB. Most vaccine candidates have been developed to strongly induce interferon-γ (IFN-γ)-producing T-helper type 1 (Th1) cell responses; however, accumulating evidence has suggested that other immune factors are required for optimal protection against Mycobacterium tuberculosis (Mtb) infection. In this review, we briefly describe the five hurdles that must be overcome to develop more effective TB vaccines, including those with various purposes and tested in recent promising clinical trials. In addition, we discuss the current knowledge gaps between preclinical experiments and clinical studies regarding peripheral versus tissue-specific immune responses, different underlying conditions of individuals, and newly emerging immune correlates of protection. Moreover, we propose how recently discovered TB risk or susceptibility factors can be better utilized as novel biomarkers for the evaluation of vaccine-induced protection to suggest more practical ways to develop advanced TB vaccines. Vaccines are the most effective tools for reducing mortality and morbidity from infectious diseases, and more advanced technologies and a greater understanding of host-pathogen interactions will provide feasibility and rationale for novel vaccine design and development.
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Affiliation(s)
- Hongmin Kim
- Department of Microbiology, Institute for Immunology and Immunological Diseases, Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Han-Gyu Choi
- Department of Microbiology and Medical Science, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Sung Jae Shin
- Department of Microbiology, Institute for Immunology and Immunological Diseases, Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul, Republic of Korea
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Monocyte-to-lymphocyte ratio is significantly associated with positive QuantiFERON-TB Gold-In-Tube and adult survival: an observational study. Sci Rep 2022; 12:20406. [PMID: 36437261 PMCID: PMC9701699 DOI: 10.1038/s41598-022-24376-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 11/14/2022] [Indexed: 11/28/2022] Open
Abstract
This study aimed to find significant factors associated with tuberculosis (TB) infection and disease development. The participants were from National Health and Nutrition Examination Survey (NHANES) and National Death Index (NDI). The tuberculosis infection was defined as a positive QuantiFERON-TB Gold-In-Tube (QFT-GIT). The Least Absolute Shrinkage and Selection Operator (LASSO) model was used to screen variables associated with QFT-GIT among 23 laboratory measures. Then the logistic regression analyses were performed to assess the independent factors, followed by a comprehensive nomogram model construction. Receiver operating characteristic (ROC) and Decision Curve (DCA) analyses were used to assess the performance of comprehensive model on QFT-GIT result and death risk. Of 5256 individuals included, 521 individuals had positive QFT-GIT. LASSO analysis indicated that 11 variables were associated with QFT-GIT result, and logistic regression analyses further found sodium and monocyte-to-lymphocyte ratio (MLR) were independent factors. After adjusting for potential confounders, the correlation of sodium and MLR with QFT-GIT result was still observed. The comprehensive model based on sodium, MLR, and important clinical characteristics can predict 0.8 probability of positive QFT-GIT and achieve more clinical net benefit. ROC analysis by training and validation sets showed the favorable prediction performance. Comprehensive model also presented favorable performance in evaluating the death risk of individuals with positive QFT-GIT. We also found MLR rather than sodium was independently related to the death risk. Both MLR itself and comprehensive model were all significantly related to the positive QFT-GIT and death risk, which might participate in the initiation and progression of tuberculosis infection.
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Adane T, Melku M, Ayalew G, Bewket G, Aynalem M, Getawa S. Accuracy of monocyte to lymphocyte ratio for tuberculosis diagnosis and its role in monitoring anti-tuberculosis treatment: Systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e31539. [PMID: 36343023 PMCID: PMC9646665 DOI: 10.1097/md.0000000000031539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND High monocyte to lymphocyte ratio (MLR) values may be associated with the risk of active tuberculosis (TB) infection in adults, infants, and postpartum women with HIV infection. It may also serve as an indicator of the effectiveness of anti-TB treatment. Thus, the main aim of this study is to ascertain the accuracy of MLR for the diagnosis of TB and its role in monitoring the effectiveness of anti-TB therapy. METHODS This systematic review and meta-analysis followed the preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. All statistical analyses were performed using STATA 11 and Meta-DiSc software. The Quality assessment of Diagnostic Accuracy Studies tool was used to evaluate the methodological quality of the included studies. The area under the hierarchical summary receiver-operating characteristic hierarchical summary ROC curve [(HSROC) curve (AUC)] was also calculated as an indicator of diagnostic accuracy. RESULTS A total of 15 articles were included in this study. Accordingly, the result showed that elevated MLR is associated with increased risks of TB disease [odd ratio = 3.11 (95% CI: 1.40-6.93)]. The pooled sensitivity and specificity of MLR for identifying TB were 79.5% (95% CI: 68.5-87.3) and 80.2% (95% CI: 67.3-88.9), respectively. The AUC of HSROC was 0.88 (95% CI: 0.857-0.903), indicating the excellent diagnostic performance of MLR for TB. This study also showed that there is a significant reduction in the MLR value after anti-TB treatment in TB patients (standardized mean difference = 0.68; 95% CI: 0.007, 1.43). CONCLUSIONS Generally, MLR can be considered as a crucial biomarker to identify TB and monitor the effectiveness of anti-TB therapy.
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Affiliation(s)
- Tiruneh Adane
- Department of Hematology and Immunohematology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
- *Correspondence: Tiruneh Adane, Department of Hematology and Immunohematology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, P.O. BOX 196, Gondar, Ethiopia (e-mail: )
| | - Mulugeta Melku
- Department of Hematology and Immunohematology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Getnet Ayalew
- Department of Medical Microbiology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Gezahegn Bewket
- Department of Immunology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Melak Aynalem
- Department of Hematology and Immunohematology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Solomon Getawa
- Department of Hematology and Immunohematology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Malik AA, Gandhi NR, Marcy O, Walters E, Tejiokem M, Chau GD, Omer SB, Lash TL, Becerra MC, Njuguna IN, LaCourse SM, Maleche-Obimbo E, Wamalwa D, John-Stewart GC, Cranmer LM. Development of a Clinical Prediction Score Including Monocyte-to-Lymphocyte Ratio to Inform Tuberculosis Treatment Among Children With HIV: A Multicountry Study. Open Forum Infect Dis 2022; 9:ofac548. [PMID: 36381621 PMCID: PMC9645646 DOI: 10.1093/ofid/ofac548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 10/12/2022] [Indexed: 11/13/2022] Open
Abstract
Background Clinical pediatric tuberculosis (TB) diagnosis may lead to overdiagnosis particularly among children with human immunodeficiency virus (CHIV). We assessed the performance of monocyte-lymphocyte ratio (MLR) as a diagnostic biomarker and constructed a clinical prediction score to improve specificity of TB diagnosis in CHIV with limited access to microbiologic testing. Methods We pooled data from cohorts of children aged ≤13 years from Vietnam, Cameroon, and South Africa to validate the use of MLR ≥0.378, previously found as a TB diagnostic marker among CHIV. Using multivariable logistic regression, we created an internally validated prediction score for diagnosis of TB disease in CHIV. Results The combined cohort had 601 children (median age, 1.9 [interquartile range, 0.9-5.3] years); 300 (50%) children were male, and 283 (47%) had HIV. Elevated MLR ≥0.378 had sensitivity of 36% (95% confidence interval [CI], 23%-51%) and specificity of 79% (95% CI, 71%-86%) among CHIV in the validation cohort. A model using MLR ≥0.28, age ≥4 years, tuberculin skin testing ≥5 mm, TB contact history, fever >2 weeks, and chest radiograph suggestive of TB predicted active TB disease in CHIV with an area under the receiver operating characteristic curve of 0.85. A prediction score of ≥5 points had a sensitivity of 94% and specificity of 48% to identify confirmed TB, and a sensitivity of 82% and specificity of 48% to identify confirmed and unconfirmed TB groups combined. Conclusions Our score has comparable sensitivity and specificity to algorithms including microbiological testing and should enable clinicians to rapidly initiate TB treatment among CHIV when microbiological testing is unavailable.
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Affiliation(s)
- Amyn A Malik
- Correspondence: Amyn A. Malik, PhD, Yale Institute for Global Health, 1 Church St, Suite 340, New Haven, CT 06510 ()
| | - Neel R Gandhi
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Olivier Marcy
- Epidemiology and Public Health Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
- Centre INSERM U1219, Bordeaux Population Health, University of Bordeaux, Bordeaux, France
| | - Elisabetta Walters
- Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- John Walton Muscular Dystrophy Research Centre, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | | | | | - Saad B Omer
- Yale Institute for Global Health, New Haven, Connecticut, USA
- Yale School of Medicine, New Haven, Connecticut, USA
- Yale School of Public Health, New Haven, Connecticut, USA
| | - Timothy L Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Mercedes C Becerra
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Partners In Health, Boston, Massachusetts, USA
| | - Irene N Njuguna
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Sylvia M LaCourse
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | | | - Dalton Wamalwa
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
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Compagno M, Navarra A, Campogiani L, Coppola L, Rossi B, Iannetta M, Malagnino V, Parisi SG, Mariotti B, Cerretti R, Arcese W, Goletti D, Andreoni M, Sarmati L. Latent Tuberculosis Infection in Haematopoietic Stem Cell Transplant Recipients: A Retrospective Italian Cohort Study in Tor Vergata University Hospital, Rome. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph191710693. [PMID: 36078409 PMCID: PMC9518118 DOI: 10.3390/ijerph191710693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/23/2022] [Accepted: 08/24/2022] [Indexed: 05/17/2023]
Abstract
The results of tuberculosis (TB) screening and reactivation in a cohort of 323 adult patients undergoing haematopoietic stem cell transplantation (HSCT) from 2015 to 2019 at the University Hospital of Tor Vergata, Rome, Italy, were reported. A total of 260 patients, 59 (18.3%) autologous and 264 (81.7%) allogeneic transplants, underwent Interferon Release (IFN)-γ (IGRA) test screening: 228 (87.7%) were negative, 11 (4.2%) indeterminate and 21 (8.1%) positive. Most of the IGRA-positive patients were of Italian origin (95.2%) and significantly older than the IGRA-negative (p < 0.001); 22 (8.5%) patients underwent a second IGRA during the first year after transplantation, and 1 tested positive for IGRA. Significantly lower monocyte (p = 0.044) and lymphocyte counts (p = 0.009) were detected in IGRA negative and IGRA indeterminate patients, respectively. All latent TB patients underwent isoniazid prophylaxis, and none of them progressed to active TB over a median follow-up period of 63.4 months. A significant decline in TB screening practices was shown from 2015 to 2019, and approximately 19% of patients were not screened. In conclusion, 8.1% of our HSCT population had LTBI, all received INH treatment, and no reactivation of TB was observed during the follow-up period. In addition, 19% escaped screening and 8% of these came from countries with a medium TB burden, therefore at higher risk of possible development of TB.
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Affiliation(s)
- Mirko Compagno
- Clinical Infectious Diseases Unit, Tor Vergata Hospital, 00133 Rome, Italy
| | - Assunta Navarra
- Clinical Epidemiology Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, 00161 Rome, Italy
| | - Laura Campogiani
- Clinical Infectious Diseases Unit, Tor Vergata Hospital, 00133 Rome, Italy
| | - Luigi Coppola
- Clinical Infectious Diseases Unit, Tor Vergata Hospital, 00133 Rome, Italy
| | - Benedetta Rossi
- Clinical Infectious Diseases, Department of System Medicine, Tor Vergata University, 00133 Rome, Italy
| | - Marco Iannetta
- Clinical Infectious Diseases, Department of System Medicine, Tor Vergata University, 00133 Rome, Italy
| | - Vincenzo Malagnino
- Clinical Infectious Diseases, Department of System Medicine, Tor Vergata University, 00133 Rome, Italy
| | - Saverio G. Parisi
- Department of Molecular Medicine, University of Padova, Via Gabelli, 63, 35100 Padova, Italy
| | - Benedetta Mariotti
- Department of Biomedicine and Prevention, University Tor Vergata of Roma, 00133 Rome, Italy
- Rome Transplant Network, Tor Vergata University Hospital, 00133 Rome, Italy
| | - Raffaella Cerretti
- Department of Biomedicine and Prevention, University Tor Vergata of Roma, 00133 Rome, Italy
- Rome Transplant Network, Tor Vergata University Hospital, 00133 Rome, Italy
| | - William Arcese
- Department of Biomedicine and Prevention, University Tor Vergata of Roma, 00133 Rome, Italy
- Rome Transplant Network, Tor Vergata University Hospital, 00133 Rome, Italy
| | - Delia Goletti
- Translational Research Unit, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, 00161 Rome, Italy
| | - Massimo Andreoni
- Clinical Infectious Diseases, Department of System Medicine, Tor Vergata University, 00133 Rome, Italy
| | - Loredana Sarmati
- Clinical Infectious Diseases, Department of System Medicine, Tor Vergata University, 00133 Rome, Italy
- Correspondence: ; Tel./Fax: +39-0672596873
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Buttle TS, Hummerstone CY, Billahalli T, Ward RJB, Barnes KE, Marshall NJ, Spong VC, Bothamley GH. The monocyte-to-lymphocyte ratio: Sex-specific differences in the tuberculosis disease spectrum, diagnostic indices and defining normal ranges. PLoS One 2021; 16:e0247745. [PMID: 34460817 PMCID: PMC8405018 DOI: 10.1371/journal.pone.0247745] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 07/19/2021] [Indexed: 11/29/2022] Open
Abstract
Background The monocyte-to-lymphocyte ratio (MLR) has been advocated as a biomarker in tuberculosis. Our objective was to evaluate its clinical value and associations. Methods Blood counts, inflammatory markers and clinical parameters were measured in patients with and those screened for tuberculosis. Complete blood counts (CBCs) from a multi-ethnic population aged 16 to 65 years were evaluated; a sub-group with normal hematological indices was used to define the range of MLRs. Results Multivariate analysis in proven tuberculosis (n = 264) indicated MLR associated with low serum albumin, high white cell counts and a positive culture; values were higher in sputum smear-positive pulmonary tuberculosis (S+PTB). Analysis in S+PTB (n = 296) showed higher MLRs in males and those with high neutrophil counts, low serum albumin and high C-reactive protein. The diagnostic value of MLRs was assessed by comparing notified patients with TB (n = 264) with denotified cases (n = 50), active case-finding in non-contacts (TB n = 111 and LTBI n = 373) and contacts of S+PTB (n = 149) with S+PTB found at screening (n = 75). Sensitivities and specificities ranged from 58.0–62.5% and 50.0–70.0% respectively for optimal cut-off values, defined by ROC curves. In CBCs obtained over one month, ratios correlated with neutrophil counts (ρ = 0.48, P<0.00001, n = 14,573; MLR = 0.45 at 8–8.9 x 109/L) and were higher in males than females (P<0.0001). The MLR range (mean ± 2SD) in those with normal hematological indices (n = 3921: females 0.122–0.474; males 0.136–0.505) paralleled LTBI MLRs. Ratios did not predict death (n = 29) nor response to treatment (n = 178 S+PTB with follow-up CBCs). Ratios were higher in males than female in the 16–45 years age group, where immune differences due to sex hormones are likely greatest. Conclusions Severe tuberculosis and male sex associated with high MLRs; the same variables likely affect the performance of other biomarkers. The ratio performed poorly as a clinical aid.
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Affiliation(s)
- Thomas S. Buttle
- Department of Respiratory Medicine, Homerton University Hospital, London, United Kingdom
| | - Claire Y. Hummerstone
- Department of Respiratory Medicine, Homerton University Hospital, London, United Kingdom
| | - Thippeswamy Billahalli
- Department of Respiratory Medicine, Homerton University Hospital, London, United Kingdom
| | - Richard J. B. Ward
- Department of Respiratory Medicine, Homerton University Hospital, London, United Kingdom
| | - Korina E. Barnes
- Microbiology Department, Homerton University Hospital, London, United Kingdom
| | - Natalie J. Marshall
- Microbiology Department, Homerton University Hospital, London, United Kingdom
| | - Viktoria C. Spong
- Department of Respiratory Medicine, Homerton University Hospital, London, United Kingdom
| | - Graham H. Bothamley
- Department of Respiratory Medicine, Homerton University Hospital, London, United Kingdom
- Department of Immunobiology, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
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White AD, Sibley L, Gullick J, Sarfas C, Clark S, Fagrouch Z, Verschoor E, Salguero FJ, Dennis M, Sharpe S. TB and SIV Coinfection; a Model for Evaluating Vaccine Strategies against TB Reactivation in Asian Origin Cynomolgus Macaques: A Pilot Study Using BCG Vaccination. Vaccines (Basel) 2021; 9:945. [PMID: 34579182 PMCID: PMC8473354 DOI: 10.3390/vaccines9090945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/12/2021] [Accepted: 08/16/2021] [Indexed: 11/17/2022] Open
Abstract
This pilot study aimed to determine the utility of a cynomolgus macaque model of coinfection with simian immunodeficiency virus (SIV) for the assessment of vaccines designed to prevent reactivation of TB. Following infection caused by aerosol exposure to an ultralow dose of Mycobacterium tuberculosis (M. tb), data trends indicated that subsequent coinfection with SIVmac32H perturbed control of M. tb infection as evidenced by the increased occurrence of progressive disease in this group, higher levels of pathology and increased frequency of progressive tuberculous granulomas in the lung. BCG vaccination led to improved control of TB-induced disease and lower viral load in comparison to unvaccinated coinfected animals. The M. tb-specific IFNγ response after exposure to M. tb, previously shown to be associated with bacterial burden, was lower in the BCG-vaccinated group than in the unvaccinated groups. Levels of CD4+ and CD8+ T cells decreased in coinfected animals, with counts recovering more quickly in the BCG-vaccinated group. This pilot study provides proof of concept to support the use of the model for evaluation of interventions against reactivated/exacerbated TB caused by human immunodeficiency virus (HIV) infection.
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Affiliation(s)
- Andrew D. White
- Public Health England, National Infections Service, Porton Down, Salisbury SP4 0JG, UK; (A.D.W.); (J.G.); (C.S.); (S.C.); (F.J.S.); (M.D.); (S.S.)
| | - Laura Sibley
- Public Health England, National Infections Service, Porton Down, Salisbury SP4 0JG, UK; (A.D.W.); (J.G.); (C.S.); (S.C.); (F.J.S.); (M.D.); (S.S.)
| | - Jennie Gullick
- Public Health England, National Infections Service, Porton Down, Salisbury SP4 0JG, UK; (A.D.W.); (J.G.); (C.S.); (S.C.); (F.J.S.); (M.D.); (S.S.)
| | - Charlotte Sarfas
- Public Health England, National Infections Service, Porton Down, Salisbury SP4 0JG, UK; (A.D.W.); (J.G.); (C.S.); (S.C.); (F.J.S.); (M.D.); (S.S.)
| | - Simon Clark
- Public Health England, National Infections Service, Porton Down, Salisbury SP4 0JG, UK; (A.D.W.); (J.G.); (C.S.); (S.C.); (F.J.S.); (M.D.); (S.S.)
| | - Zahra Fagrouch
- Department of Virology, Biomedical Primate Research Centre, Lange Kleiweg 161, 2288 GJ Rijswijk, The Netherlands; (Z.F.); (E.V.)
| | - Ernst Verschoor
- Department of Virology, Biomedical Primate Research Centre, Lange Kleiweg 161, 2288 GJ Rijswijk, The Netherlands; (Z.F.); (E.V.)
| | - Francisco J. Salguero
- Public Health England, National Infections Service, Porton Down, Salisbury SP4 0JG, UK; (A.D.W.); (J.G.); (C.S.); (S.C.); (F.J.S.); (M.D.); (S.S.)
| | - Mike Dennis
- Public Health England, National Infections Service, Porton Down, Salisbury SP4 0JG, UK; (A.D.W.); (J.G.); (C.S.); (S.C.); (F.J.S.); (M.D.); (S.S.)
| | - Sally Sharpe
- Public Health England, National Infections Service, Porton Down, Salisbury SP4 0JG, UK; (A.D.W.); (J.G.); (C.S.); (S.C.); (F.J.S.); (M.D.); (S.S.)
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10
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High-dose Mycobacterium tuberculosis aerosol challenge cannot overcome BCG-induced protection in Chinese origin cynomolgus macaques; implications of natural resistance for vaccine evaluation. Sci Rep 2021; 11:12274. [PMID: 34112845 PMCID: PMC8192909 DOI: 10.1038/s41598-021-90913-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/19/2021] [Indexed: 12/01/2022] Open
Abstract
This study describes the use of cynomolgus macaques of Chinese origin (CCM) to evaluate the efficacy and immunogenicity of the BCG vaccine against high dose aerosol Mycobacterium tuberculosis challenge. Progressive disease developed in three of the unvaccinated animals within 10 weeks of challenge, whereas all six vaccinated animals controlled disease for 26 weeks. Three unvaccinated animals limited disease progression, highlighting the intrinsic ability of this macaque species to control disease in comparison to macaques of other species and genotypes. Low levels of IFNγ were induced by BCG vaccination in CCM suggesting that IFNγ alone does not provide a sufficiently sensitive biomarker of vaccination in this model. An early response after challenge, together with the natural bias towards terminal effector memory T-cell populations and the contribution of monocytes appears to enhance the ability of CCM to naturally control infection. The high dose aerosol challenge model of CCM has value for examination of the host immune system to characterise control of infection which would influence future vaccine design. Although it may not be the preferred platform for the assessment of prophylactic vaccine candidates, the model could be well suited for testing post-exposure vaccination strategies and drug evaluation studies.
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11
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The potential of CBC-derived ratios (monocyte-to-lymphocyte, neutrophil-to-lymphocyte, and platelet-to-lymphocyte) to predict or diagnose incident TB infection in Tanzanian adolescents. BMC Infect Dis 2020; 20:609. [PMID: 32811463 PMCID: PMC7433160 DOI: 10.1186/s12879-020-05331-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 08/09/2020] [Indexed: 12/21/2022] Open
Abstract
Background Ratios of different immune cell populations (i.e., monocyte-to-lymphocyte, neutrophil-to-lymphocyte, and platelet-to-lymphocyte ratios) have been studied as a means of predicting future tuberculosis (TB) disease risk or to assist in the diagnosis of incident TB disease. No studies to-date, however, have evaluated the potential of these ratios to predict or assist in the diagnosis of incident TB infection - the first step in the natural history of TB disease. Methods In this prospective study, we evaluated the complete blood count (CBC)-derived metrics of monocyte-to-lymphocyte ratio (MLR), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) as predictors of future TB infection risk or aids in the diagnosis of TB infection among 145 Tanzanian adolescents enrolled in the DAR-901 vaccine trial, using paired CBCs and interferon-gamma release assays (IGRAs) obtained at 0, 60 and 720 days after study enrollment. Results At baseline, there were no significant differences between study participants who remained persistently IGRA negative throughout the study period and those who subsequently converted to IGRA positive with respect to MLR (0.18 vs 0.17, p = 0.10), NLR (0.88 vs 1.02, p = 0.08), or PLR (115 vs 120, p = 0.28). Similarly, no significant differences were noted with respect to MLR, NLR, and PLR between IGRA converters and time-matched negative controls at the time of IGRA conversion. With respect to other blood cell measures, however, there were modest but significant differences between IGRA negatives and IGRA converters with respect to red blood cell count (4.8 vs 4.6 × 106 cells/mcL, p = 0.008), hemoglobin (12.6 vs 12.3 g/dL, p = 0.01), and hematocrit (38.8 vs 37.8%, p = 0.005). Conclusions In contrast to prior studies that have suggested that the ratios of different immune cell populations are associated with development of TB disease, our present findings do not demonstrate an association between these ratios and the development of TB infection. However, decreased red blood cell measures were associated with the subsequent development of TB infection, suggesting either that dysregulation of iron metabolism may play a role in TB pathogenesis or that following TB infection, iron dysregulation may precede IGRA positivity. Trial registration Clinicaltrials.gov NCT02712424. Date of registration: March 14, 2016.
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12
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Wang Q, Liu F, Zhao Y, Cui B, Ban Y. Can neutrophil-to-lymphocyte and monocyte-to-lymphocyte ratios be useful markers for predicting missed abortion in the first trimester of pregnancy? J Obstet Gynaecol Res 2020; 46:1702-1710. [PMID: 32588480 DOI: 10.1111/jog.14349] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 04/22/2020] [Accepted: 05/23/2020] [Indexed: 01/04/2023]
Abstract
AIM To explore whether neutrophil-to-lymphocyte ratio (NLR) and monocyte-to-lymphocyte ratio (MLR) could predict missed abortion (MA) at 7-13 week's gestation. METHODS A total of 363 women with a diagnosis of MA and 232 women with normal pregnancy at 7-13 week's gestation, who visited our hospital from June 2012 to May 2018 were retrospectively analyzed. At 7 week's gestation, total and differential leukocyte counts, NLR and MLR were compared between women with MA (n = 69) and normal controls (n = 53). The receiver operating characteristic curve was used to select the optimal indicator and its cut-off point. The role of the optimal indicator was further assessed at 8-13 week's gestation. RESULTS The mean white blood cell counts, the mean neutrophil counts, the median monocyte counts, the mean NLR and the median MLR in women with MA were significantly lower than those in normal controls (P < 0.05, respectively).The neutrophil counts had the highest area under the curve (AUC) value of 0.772 (95% confidence interval 0.675-0.869) with a cut-off value of 4.870 × 109 /L, and the sensitivity was 72.46%, the specificity was 69.81%, positive predictive value was 75.76%, and negative predictive value was 66.07%. In addition, the neutrophil counts were also significantly lower in MA groups than those in normal controls at 8-13 week's gestation, and all had the highest AUC values. CONCLUSION Neutrophil counts may predict MA in the first trimester of pregnancy, which may provide a promising marker to diagnose missed abortion as early as 7 week's gestation.
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Affiliation(s)
- Qingjie Wang
- Institute of Basic Medical Sciences, Qilu Hospital, Shandong University, Jinan, China
| | - Fen Liu
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, Jinan, China
| | - Ying Zhao
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, Jinan, China
| | - Baoxia Cui
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, Jinan, China
| | - Yanli Ban
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, Jinan, China
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Ohata PJ, Kerr SJ, Avihingsanon A, Ramautarsing R, Gatechompol S, Ueaphongsukkit T, Phanuphak N, Kroon E, Ubolyam S, Colby D, Phanuphak P. Conference proceedings from the 22nd Bangkok International Symposium on HIV Medicine. Future Virol 2020. [DOI: 10.2217/fvl-2020-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The Bangkok International Symposium on HIV Medicine is one of the longest running and largest international conferences in the Asia–Pacific, providing healthcare workers with the most up-to-date information pertaining to HIV and coinfections. In the third week of January 2020, 500 HIV researchers and service providers from over 21 countries worldwide gathered in Bangkok to share data and experiences in the treatment and prevention of HIV, TB and sexually transmitted infections. Highlights of the 2020 symposium included a roundtable discussion of pre-exposure prophylaxis, a 1-day forum on TB, the potential for a HBV cure and, for the first time, oral presentations from four young investigators from the region.
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Affiliation(s)
- Pirapon June Ohata
- HIV-NAT, Thai Red Cross – AIDS Research Centre, 104 Ratchadamri Rd, Pathumwan, Bangkok 10330, Thailand
| | - Stephen J Kerr
- HIV-NAT, Thai Red Cross – AIDS Research Centre, 104 Ratchadamri Rd, Pathumwan, Bangkok 10330, Thailand
- Biostatistics Excellence Centre, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
- The Kirby Institute, University of New South Wales, NSW, Sydney 2052, Australia
| | - Anchalee Avihingsanon
- HIV-NAT, Thai Red Cross – AIDS Research Centre, 104 Ratchadamri Rd, Pathumwan, Bangkok 10330, Thailand
- Tuberculosis Research Unit (TB RU), Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Reshmie Ramautarsing
- PREVENTION, Thai Red Cross – AIDS Research Centre, 104 Ratchadamri Rd., Pathumwan, Bangkok 10330, Thailand
| | - Sivaporn Gatechompol
- HIV-NAT, Thai Red Cross – AIDS Research Centre, 104 Ratchadamri Rd, Pathumwan, Bangkok 10330, Thailand
- Tuberculosis Research Unit (TB RU), Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Thornthun Ueaphongsukkit
- HIV-NAT, Thai Red Cross – AIDS Research Centre, 104 Ratchadamri Rd, Pathumwan, Bangkok 10330, Thailand
- Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Nittaya Phanuphak
- PREVENTION, Thai Red Cross – AIDS Research Centre, 104 Ratchadamri Rd., Pathumwan, Bangkok 10330, Thailand
| | - Eugene Kroon
- SEARCH, Thai Red Cross – AIDS Research Centre, 104 Ratchadamri Rd., Pathumwan, Bangkok 10330, Thailand
| | - Sasiwimol Ubolyam
- HIV-NAT, Thai Red Cross – AIDS Research Centre, 104 Ratchadamri Rd, Pathumwan, Bangkok 10330, Thailand
| | - Donn Colby
- SEARCH, Thai Red Cross – AIDS Research Centre, 104 Ratchadamri Rd., Pathumwan, Bangkok 10330, Thailand
- Henry M Jackson Foundation, Bethesda, MD 20817, USA
- US Military HIV Research Program, Silver Spring, MD 20910, USA
| | - Praphan Phanuphak
- HIV-NAT, Thai Red Cross – AIDS Research Centre, 104 Ratchadamri Rd, Pathumwan, Bangkok 10330, Thailand
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Monocyte-to-Lymphocyte Ratio Is Associated With Tuberculosis Disease and Declines With Anti-TB Treatment in HIV-Infected Children. J Acquir Immune Defic Syndr 2019; 80:174-181. [PMID: 30399036 DOI: 10.1097/qai.0000000000001893] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND The blood monocyte-to-lymphocyte ratio (MLR) is associated with active tuberculosis (TB) in adults but has not been evaluated as a TB diagnostic biomarker in HIV-infected children in whom respiratory sampling is difficult. SETTING In a cohort of HIV-infected hospitalized Kenyan children initiating antiretroviral therapy, absolute monocyte and lymphocyte counts were determined at enrollment and 4, 12, and 24 weeks thereafter. METHODS Children were classified as confirmed, unconfirmed, or unlikely pulmonary TB. Receiver operating characteristic curves of MLR cutoff values were generated to distinguish children with confirmed TB from those with unconfirmed and unlikely TB. General estimating equations were used to estimate change in the MLR over time by TB status. RESULTS Of 160 children with median age 23 months, 13 (8.1%) had confirmed TB and 67 (41.9%) had unconfirmed TB. The median MLR among children with confirmed TB {0.407 [interquartile range (IQR) 0.378-0.675]} was higher than the MLR in children with unconfirmed [0.207 (IQR 0.148-0.348), P < 0.01] or unlikely [0.212 (IQR 0.138-0.391), P = 0.01] TB. The MLR above 0.378 identified children with confirmed TB with 77% sensitivity, 78% specificity, 24% positive predictive value, and 97% negative predictive value. After TB treatment, the median MLR declined in children with confirmed TB and levels were similar to children with unlikely TB after 12 weeks. CONCLUSIONS The blood MLR distinguished HIV-infected children with confirmed TB from those with unlikely TB and declined with TB treatment. The MLR may be a useful diagnostic tool for TB in settings where respiratory-based microbiologic confirmation is inaccessible.
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Prabowo SA, Smith SG, Seifert K, Fletcher HA. Impact of individual-level factors on Ex vivo mycobacterial growth inhibition: Associations of immune cell phenotype, cytomegalovirus-specific response and sex with immunity following BCG vaccination in humans. Tuberculosis (Edinb) 2019; 119:101876. [PMID: 31698310 DOI: 10.1016/j.tube.2019.101876] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 08/02/2019] [Accepted: 09/29/2019] [Indexed: 01/18/2023]
Abstract
Understanding factors associated with varying efficacy of Bacillus Calmette-Guérin (BCG) would aid the development of improved vaccines against tuberculosis (TB). In addition, investigation of individual-level factors affecting mycobacterial-specific immune responses could provide insight into confounders of vaccine efficacy in clinical trials. Mycobacterial growth inhibition assays (MGIA) have been developed to assess vaccine immunogenicity ex vivo and provide a measure of immune function against live mycobacteria. In this study, we assessed the impact of immune cell phenotype, cytomegalovirus (CMV)-specific response and sex on ex vivo growth inhibition following historical BCG vaccination in a cohort of healthy individuals (n = 100). A higher frequency of cytokine-producing NK cells in peripheral blood was associated with enhanced ex vivo mycobacterial growth inhibition following historical BCG vaccination. A CMV-specific response was associated with T-cell activation, a risk factor for TB disease and we also observed an association between T-cell activation and ex vivo mycobacterial growth. Interestingly, BCG-vaccinated females in our cohort controlled mycobacterial growth better than males. In summary, our present study has shown that individual-level factors influence capacity to control mycobacterial growth following BCG vaccination and the MGIA could be used as a tool to assess how vaccine candidates may perform in different populations.
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Affiliation(s)
- Satria A Prabowo
- Department of Immunology and Infection, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK; Tuberculosis Centre, London School of Hygiene and Tropical Medicine, London, UK.
| | - Steven G Smith
- Department of Immunology and Infection, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK; Tuberculosis Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Karin Seifert
- Department of Immunology and Infection, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Helen A Fletcher
- Department of Immunology and Infection, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK; Tuberculosis Centre, London School of Hygiene and Tropical Medicine, London, UK
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Mahomed S, Padayatchi N, Singh J, Naidoo K. Precision medicine in resistant Tuberculosis: Treat the correct patient, at the correct time, with the correct drug. J Infect 2019; 78:261-268. [PMID: 30849440 DOI: 10.1016/j.jinf.2019.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 03/01/2019] [Accepted: 03/03/2019] [Indexed: 01/30/2023]
Abstract
Human genomic mapping has advanced molecular medicine health care and created a transformative paradigm shift towards Precision Medicine. In 2015, President Obama launched the PM initiative, encapsulated as "unique individualized data-driven treatments". Since then, this field is rapidly advancing both curative treatment and disease prevention by accounting for both individual and environmental variability. While a substantial evidence for accelerating adoption of Precision Medicine in other spheres of medicine exists, application of Precision Medicine in infectious diseases is far more complex. One of the most warranted applications of precision healthcare is in the management and treatment of Drug-resistant Tuberculosis. Application of Precision Medicine to Drug-resistant Tuberculosis could potentially change the landscape of treatment and prevention of a disease affecting vulnerable patients in impoverished communities. Poorly diagnosed and treated Drug-resistant Tuberculosis not only leads to increased mortality and morbidity but also increased transmission of DR-TB strains, fuelling ongoing high incidence rates and further infection. A Precision medicine model using individual clinical case histories used in conjunction with Mycobacterium Tuberculosis infection genomic data will better guide health care practitioners in more appropriate drug selection, and an individualized management approach. This viewpoint deliberates the intricacies of adopting a PM approach in the management of DR-TB. If applied correctly, we postulate that the research, application, and deployment of PM in DR-TB management may address the fundamental rule of PM in infectious disease: to treat the correct patient, at the correct time, with the correct drug.
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Affiliation(s)
- Sharana Mahomed
- CAPRISA, Centre for the AIDS Programme of Research in South Africa, Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Private Bag X7, Congella, 4013, Durban, South Africa.
| | - Nesri Padayatchi
- CAPRISA, Centre for the AIDS Programme of Research in South Africa, Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Private Bag X7, Congella, 4013, Durban, South Africa.
| | - Jerome Singh
- CAPRISA, Centre for the AIDS Programme of Research in South Africa, Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Private Bag X7, Congella, 4013, Durban, South Africa.
| | - Kogieleum Naidoo
- CAPRISA, Centre for the AIDS Programme of Research in South Africa, Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Private Bag X7, Congella, 4013, Durban, South Africa.
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Sousa J, Saraiva M. Paradigm changing evidence that alter tuberculosis perception and detection: Focus on latency. INFECTION GENETICS AND EVOLUTION 2018; 72:78-85. [PMID: 30576838 DOI: 10.1016/j.meegid.2018.12.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 12/12/2018] [Accepted: 12/15/2018] [Indexed: 12/23/2022]
Abstract
Tuberculosis remains a devastating disease to Mankind, ranking as the ninth cause of death worldwide. Eliminating tuberculosis as proven much more difficult than once anticipated. In addition to the delay in diagnosis and drug resistance problems that compromise the efficacy of treatment, the enormous reservoir of latently infected individuals continuously feeds the epidemics. However, targeting latency with prophylactic antibiotic administration is not possible at the populational level. Together, these issues call for a better understanding of latency, as well as for a more precise identification of individuals at high risk of reactivation. For this, recent paradigm changing evidence need to be taken into account, most notably, the existence of a tuberculosis spectrum; the genetic diversity of both humans and tuberculosis-causing bacteria; and the changes in the human population that interfere with tuberculosis. Here we discuss latency in the light of these variables and how that understanding can move forward tuberculosis research and elimination.
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Affiliation(s)
- Jeremy Sousa
- i3S - Instituto de Investigação e Inovação em Saúde, Porto, Portugal; IBMC - Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal
| | - Margarida Saraiva
- i3S - Instituto de Investigação e Inovação em Saúde, Porto, Portugal; IBMC - Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal.
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Satti I, McShane H. Current approaches toward identifying a correlate of immune protection from tuberculosis. Expert Rev Vaccines 2018; 18:43-59. [PMID: 30466332 DOI: 10.1080/14760584.2019.1552140] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Mycobacterium tuberculosis kills more people than any other pathogen. Vaccination is the most cost-effective control measure for any infectious disease. Development of an effective vaccine against tuberculosis is hindered by the uncertain predictive value of preclinical animal models, incomplete understanding of protective immunity and lack of validated immune correlates of protection (COP). AREAS COVERED Here we review what is known about protective immunity against M.tb, the preclinical and clinical cohorts that can be utilized to identify COP, and COP that have been identified to date. EXPERT COMMENTARY The identification of COP would allow the rational design and development of vaccine candidates which can then be optimized and prioritized based on the induction of these immune responses. Once validated in field efficacy trials, such COP could potentially facilitate the development and licensure of vaccines, in combination with human efficacy data. The identification and validation of COP would represent a very significant advance in TB vaccine development. Every opportunity to collect samples and cohorts on which to cross-validate pre-existing COP and identify novel COP should be exploited. Furthermore, global cooperation and collaboration on such samples will ensure that the utility of such precious samples is fully exploited.
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Affiliation(s)
- Iman Satti
- a Jenner Institute, Nuffield Department of Medicine , University of Oxford , Oxford , UK
| | - Helen McShane
- a Jenner Institute, Nuffield Department of Medicine , University of Oxford , Oxford , UK
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19
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Fletcher HA. Systems approaches to correlates of protection and progression to TB disease. Semin Immunol 2018; 39:81-87. [PMID: 30316693 DOI: 10.1016/j.smim.2018.10.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 10/01/2018] [Indexed: 12/14/2022]
Abstract
Tuberculosis (TB) is the leading cause of death due to a single infectious disease and an effective vaccine would substantially accelerate global efforts to control TB. An immune correlate of protection (CoP) from TB disease could aid vaccine optimization and licensure. This paper summarises opportunities for identifying CoP and highlights results from correlates of risk studies. Although we don't have CoP, there are ongoing efficacy trials with both disease and infection endpoints which provide opportunities for such an analysis. Transcriptomics has successfully identified robust CoR, with transcripts found in the Type I IFN pathway. Correlates of lower risk include BCG antigen specific IFN-γ and natural killer cells. Collating evidence from multiple studies using a range of systems approaches supports a role for IFN-γ in protection from TB disease. In addition, the cells that express the IFN-γ receptor are also important in protective immunity. Protection is a culmination not only of the amount of IFN-γ produced by T cells and NK cells but by the ability of IFN-γ receptor expressing monocytes to respond to IFN-γ. To better understand IFN-γ as a correlate we need to understand host-factors such as age, sex, co-infection, nutritional status and stress which may alter or impair the ability of cells to respond to IFN-γ. These studies highlight recent advances in our understanding of the immune mechanisms of TB disease risk and show the importance of whole systems approaches to correlates of risk analysis. CoP may be useful tools for specific vaccine products in specific populations, but a well-designed CoR analysis can identify novel immune mechanisms and provide insights critical for the development of new and better TB vaccines.
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Affiliation(s)
- Helen A Fletcher
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK.
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Zelmer A, Stockdale L, Prabowo SA, Cia F, Spink N, Gibb M, Eddaoudi A, Fletcher HA. High monocyte to lymphocyte ratio is associated with impaired protection after subcutaneous administration of BCG in a mouse model of tuberculosis. F1000Res 2018; 7:296. [PMID: 30026926 PMCID: PMC6039926 DOI: 10.12688/f1000research.14239.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/06/2018] [Indexed: 07/17/2024] Open
Abstract
Background: The only available tuberculosis (TB) vaccine, Bacillus Calmette-Guérin (BCG), has variable efficacy. New vaccines are therefore urgently needed. Why BCG fails is incompletely understood, and the tools used for early assessment of new vaccine candidates do not account for BCG variability. Taking correlates of risk of TB disease observed in human studies and back-translating them into mice to create models of BCG variability should allow novel vaccine candidates to be tested early in animal models that are more representative of the human populations most at risk. Furthermore, this could help to elucidate the immunological mechanisms leading to BCG failure. We have chosen the monocyte to lymphocyte (ML) ratio as a correlate of risk of TB disease and have back-translated this into a mouse model. Methods: Four commercially available, inbred mouse strains were chosen. We investigated their baseline ML ratio by flow cytometry; extent of BCG-mediated protection from Mtb infection by experimental challenge; vaccine-induced interferon gamma (IFNγ) response by ELISPOT assay; and tissue distribution of BCG by plating tissue homogenates. Results: The ML ratio varied significantly between A/J, DBA/2, C57Bl/6 and 129S2 mice. A/J mice showed the highest BCG-mediated protection and lowest ML ratio, while 129S2 mice showed the lowest protection and higher ML ratio. We also found that A/J mice had a lower antigen specific IFNγ response than 129S2 mice. BCG tissue distribution appeared higher in A/J mice, although this was not statistically significant. Conclusions: These results suggest that the ML ratio has an impact on BCG-mediated protection in mice, in alignment with observations from clinical studies. A/J and 129S2 mice may therefore be useful models of BCG vaccine variability for early TB vaccine testing. We speculate that failure of BCG to protect from TB disease is linked to poor tissue distribution in a ML high immune environment.
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Affiliation(s)
- Andrea Zelmer
- London School of Hygiene and Tropical Medicine, Department of Immunology and Infection, Keppel Street, London, WC1E 7HT, UK
| | - Lisa Stockdale
- London School of Hygiene and Tropical Medicine, Department of Immunology and Infection, Keppel Street, London, WC1E 7HT, UK
| | - Satria A. Prabowo
- London School of Hygiene and Tropical Medicine, Department of Immunology and Infection, Keppel Street, London, WC1E 7HT, UK
| | - Felipe Cia
- London School of Hygiene and Tropical Medicine, Department of Immunology and Infection, Keppel Street, London, WC1E 7HT, UK
| | - Natasha Spink
- London School of Hygiene and Tropical Medicine, Department of Immunology and Infection, Keppel Street, London, WC1E 7HT, UK
| | - Matthew Gibb
- London School of Hygiene and Tropical Medicine, Department of Immunology and Infection, Keppel Street, London, WC1E 7HT, UK
- Baylor Institute for Immunology Research, 3434 Live Oak Street, Dallas, Texas, 75204, USA
| | - Ayad Eddaoudi
- UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Helen A. Fletcher
- London School of Hygiene and Tropical Medicine, Department of Immunology and Infection, Keppel Street, London, WC1E 7HT, UK
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Zelmer A, Stockdale L, Prabowo SA, Cia F, Spink N, Gibb M, Eddaoudi A, Fletcher HA. High monocyte to lymphocyte ratio is associated with impaired protection after subcutaneous administration of BCG in a mouse model of tuberculosis. F1000Res 2018; 7:296. [PMID: 30026926 PMCID: PMC6039926 DOI: 10.12688/f1000research.14239.2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2018] [Indexed: 11/20/2022] Open
Abstract
Background: The only available tuberculosis (TB) vaccine, Bacillus Calmette-Guérin (BCG), has variable efficacy. New vaccines are therefore urgently needed. Why BCG fails is incompletely understood, and the tools used for early assessment of new vaccine candidates do not account for BCG variability. Taking correlates of risk of TB disease observed in human studies and back-translating them into mice to create models of BCG variability should allow novel vaccine candidates to be tested early in animal models that are more representative of the human populations most at risk. Furthermore, this could help to elucidate the immunological mechanisms leading to BCG failure. We have chosen the monocyte to lymphocyte (ML) ratio as a correlate of risk of TB disease and have back-translated this into a mouse model. Methods: Four commercially available, inbred mouse strains were chosen. We investigated their baseline ML ratio by flow cytometry; extent of BCG-mediated protection from M ycobacterium tuberculosis infection by experimental challenge; vaccine-induced interferon gamma (IFNγ) response by ELISPOT assay; and tissue distribution of BCG by plating tissue homogenates. Results: The ML ratio varied significantly between A/J, DBA/2, C57Bl/6 and 129S2 mice. A/J mice showed the highest BCG-mediated protection and lowest ML ratio, while 129S2 mice showed the lowest protection and higher ML ratio. We also found that A/J mice had a lower antigen specific IFNγ response than 129S2 mice. BCG tissue distribution appeared higher in A/J mice, although this was not statistically significant. Conclusions: These results suggest that the ML ratio has an impact on BCG-mediated protection in mice, in alignment with observations from clinical studies. A/J and 129S2 mice may therefore be useful models of BCG vaccine variability for early TB vaccine testing. We speculate that failure of BCG to protect from TB disease is linked to poor tissue distribution in a ML high immune environment.
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Affiliation(s)
- Andrea Zelmer
- London School of Hygiene and Tropical Medicine, Department of Immunology and Infection, Keppel Street, London, WC1E 7HT, UK
| | - Lisa Stockdale
- London School of Hygiene and Tropical Medicine, Department of Immunology and Infection, Keppel Street, London, WC1E 7HT, UK
| | - Satria A. Prabowo
- London School of Hygiene and Tropical Medicine, Department of Immunology and Infection, Keppel Street, London, WC1E 7HT, UK
| | - Felipe Cia
- London School of Hygiene and Tropical Medicine, Department of Immunology and Infection, Keppel Street, London, WC1E 7HT, UK
| | - Natasha Spink
- London School of Hygiene and Tropical Medicine, Department of Immunology and Infection, Keppel Street, London, WC1E 7HT, UK
| | - Matthew Gibb
- London School of Hygiene and Tropical Medicine, Department of Immunology and Infection, Keppel Street, London, WC1E 7HT, UK
- Baylor Institute for Immunology Research, 3434 Live Oak Street, Dallas, Texas, 75204, USA
| | - Ayad Eddaoudi
- UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Helen A. Fletcher
- London School of Hygiene and Tropical Medicine, Department of Immunology and Infection, Keppel Street, London, WC1E 7HT, UK
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Goletti D, Lee MR, Wang JY, Walter N, Ottenhoff THM. Update on tuberculosis biomarkers: From correlates of risk, to correlates of active disease and of cure from disease. Respirology 2018; 23:455-466. [PMID: 29457312 DOI: 10.1111/resp.13272] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 12/18/2017] [Accepted: 01/22/2018] [Indexed: 12/23/2022]
Abstract
Tuberculosis (TB) remains a devastating disease, yet despite its enormous toll on global health, tools to control TB are insufficient and often outdated. TB Biomarkers (TB-BM) would constitute extremely useful tools to measure infection status and predict outcome of infection, vaccination or therapy. There are several types of TB-BM: Correlate of Infection; Correlate of TB Disease; Correlate of Increased Risk of Developing Active TB Disease; Correlate of the Curative Response to Therapy; and Correlate of Protection (CoP). Most TB-BM currently studied are host-derived BM, and consist of transcriptomic, proteomic, metabolomic, cellular markers or marker combinations ('signatures'). In particular, vaccine-inducible CoP are expected to be transformative in developing new TB vaccines as they will de-risk vaccine research and development (R&D) as well as human testing at an early stage. In addition, CoP could also help minimizing the need for preclinical studies in experimental animals. Of key importance is that TB-BM are tested and validated in different well-characterized human TB cohorts, preferably with complementary profiles and geographically diverse populations: genetic and environmental factors such as (viral) coinfections, exposure to non-tuberculous mycobacteria, nutritional status, metabolic status, age (infants vs children vs adolescents vs adults) and other factors impact host immune set points and host responses across different populations. In this study, we review the most recent advances in research into TB-BM for the diagnosis of active TB, risk of TB development and treatment-induced TB cure.
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Affiliation(s)
- Delia Goletti
- Translational Research Unit, Department of Epidemiology and Preclinical Research, National Institute for Infectious Diseases "L. Spallanzani", Rome, Italy
| | - Meng-Rui Lee
- Department of Internal Medicine, National Taiwan University Hospital, Hsinchu, Taiwan
| | - Jann-Yuan Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Nicholas Walter
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
| | - Tom H M Ottenhoff
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
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23
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Brennan MJ, Tanner R, Morris S, Scriba TJ, Achkar JM, Zelmer A, Hokey DA, Izzo A, Sharpe S, Williams A, Penn-Nicholson A, Erasmus M, Stylianou E, Hoft DF, McShane H, Fletcher HA. The Cross-Species Mycobacterial Growth Inhibition Assay (MGIA) Project, 2010-2014. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2017; 24:e00142-17. [PMID: 28701467 PMCID: PMC5585695 DOI: 10.1128/cvi.00142-17] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
The development of a functional biomarker assay in the tuberculosis (TB) field would be widely recognized as a major advance in efforts to develop and to test novel TB vaccine candidates efficiently. We present preliminary studies using mycobacterial growth inhibition assays (MGIAs) to detect Mycobacterium bovis BCG vaccine responses across species, and we extend this work to determine whether a standardized MGIA can be applied in characterizing new TB vaccines. The comparative MGIA studies reviewed here aimed to evaluate robustness, reproducibility, and ability to reflect in vivo responses. In doing so, they have laid the foundation for the development of a MGIA that can be standardized and potentially qualified. A major challenge ahead lies in better understanding the relationships between in vivo protection, in vitro growth inhibition, and the immune mechanisms involved. The final outcome would be a MGIA that could be used with confidence in TB vaccine trials. We summarize data arising from this project, present a strategy to meet the goals of developing a functional assay for TB vaccine testing, and describe some of the challenges encountered in performing and transferring such assays.
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Affiliation(s)
| | - Rachel Tanner
- The Jenner Institute, University of Oxford, Oxford, United Kingdom
| | - Sheldon Morris
- Center for Biologics Evaluation and Research, Food and Drug Administration, Bethesda, Maryland, USA
| | - Thomas J Scriba
- South African Tuberculosis Vaccine Initiative and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Jacqueline M Achkar
- Departments of Medicine, Microbiology, and Immunology, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Andrea Zelmer
- Department of Immunology and Infection, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Angelo Izzo
- Colorado State University, Fort Collins, Colorado, USA
| | - Sally Sharpe
- Public Health England, Porton Down, Salisbury, United Kingdom
| | - Ann Williams
- Public Health England, Porton Down, Salisbury, United Kingdom
| | - Adam Penn-Nicholson
- South African Tuberculosis Vaccine Initiative and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Mzwandile Erasmus
- South African Tuberculosis Vaccine Initiative and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Elena Stylianou
- The Jenner Institute, University of Oxford, Oxford, United Kingdom
| | | | - Helen McShane
- The Jenner Institute, University of Oxford, Oxford, United Kingdom
| | - Helen A Fletcher
- Department of Immunology and Infection, London School of Hygiene & Tropical Medicine, London, United Kingdom
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24
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Abstract
Immunology is a central theme when it comes to tuberculosis (TB). The outcome of human infection with Mycobacterium tuberculosis is dependent on the ability of the immune response to clear or contain the infection. In cases where this fails, the bacterium replicates, disseminates within the host, and elicits a pathologic inflammatory response, and disease ensues. Clinical presentation of TB disease is remarkably heterogeneous, and the disease phenotype is largely dependent on host immune status. Onward transmission of M. tuberculosis to new susceptible hosts is thought to depend on an excessive inflammatory response causing a breakdown of the lung matrix and formation of lung cavities. But this varies in cases of underlying immunological dysfunction: for example, HIV-1 infection is associated with less cavitation, while diabetes mellitus comorbidity is associated with increased cavitation and risk of transmission. In compliance with the central theme of immunology in tuberculosis, we rely on detection of an adaptive immune response, in the form of interferon-gamma release assays or tuberculin skin tests, to diagnose infection with M. tuberculosis. Here we review the immunology of TB in the human host, focusing on cellular and humoral adaptive immunity as well as key features of innate immune responses and the underlying immunological dysfunction which associates with human TB risk factors. Our review is restricted to human immunology, and we highlight distinctions from the immunological dogma originating from animal models of TB, which pervade the field.
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25
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Mathad JS, Bhosale R, Balasubramanian U, Kanade S, Mave V, Suryavanshi N, Gupte N, Joshi S, Chandanwale A, Dupnik KM, Kulkarni V, Deshpande P, Fitzgerald DW, Gupta A. Quantitative IFN-γ and IL-2 Response Associated with Latent Tuberculosis Test Discordance in HIV-infected Pregnant Women. Am J Respir Crit Care Med 2017; 193:1421-8. [PMID: 26765255 DOI: 10.1164/rccm.201508-1595oc] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Pregnant women with latent tuberculosis infection (LTBI) are at high risk for development of TB, especially if infected with HIV. OBJECTIVES To assess the performance of LTBI tests in pregnant and postpartum women infected with HIV, investigate the immunology behind discordance in pregnancy, and explore the implications for the development of postpartum TB. METHODS We screened pregnant women in their second/third trimester and at delivery for LTBI using the tuberculin skin test (TST) and IFN-γ release assay (IGRA) (QuantiFERON Gold). A subset of antepartum women had longitudinal testing, with repeat testing at delivery and postpartum and additional cytokines measured from the IGRA supernatant. The kappa statistic and Wilcoxon rank sum test were used to determine agreement and comparison of cytokine concentrations, respectively. MEASUREMENTS AND MAIN RESULTS Of 252 enrolled, 71 (28%) women had a positive IGRA but only 27 (10%) had a positive TST (P < 0.005). There was 75% agreement (kappa, 0.25). When stratified by pregnancy versus delivery, 20% had IGRA(+)/TST(-) discordance at each time point. A positive IGRA was associated with known TB contact (odds ratio, 3.6; confidence interval, 1.2-11.1; P = 0.02). Compared with IGRA(+)/TST(+), women with IGRA(+)/TST(-) discordance had significantly less IFN-γ (1.85 vs. 3.48 IU/ml; P = 0.02) and IL-2 (46.17 vs. 84.03 pg/ml; P = 0.01). Five developed postpartum TB, of which three had IGRA(+)/TST(-) discordance during pregnancy. CONCLUSIONS Choice of LTBI test in pregnant women infected with HIV affects results. Pregnant women with IGRA(+)/TST(-) discordance had less IFN-γ and IL-2 than those with concordant-positive results and may represent an especially high-risk subset for the development of active TB postpartum.
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Affiliation(s)
- Jyoti S Mathad
- 1 Center for Global Health, Division of Infectious Diseases, Weill Cornell Medical College, New York, New York
| | - Ramesh Bhosale
- 2 Department of Obstetrics and Gynaecology, Byramjee Jeejeebhoy Government Medical College/Sassoon General Hospital, Pune, India
| | - Usha Balasubramanian
- 3 Byramjee Jeejeebhoy Government Medical College-Johns Hopkins Clinical Trials Unit, Pune, India
| | - Savita Kanade
- 3 Byramjee Jeejeebhoy Government Medical College-Johns Hopkins Clinical Trials Unit, Pune, India
| | - Vidya Mave
- 3 Byramjee Jeejeebhoy Government Medical College-Johns Hopkins Clinical Trials Unit, Pune, India.,4 Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Nishi Suryavanshi
- 3 Byramjee Jeejeebhoy Government Medical College-Johns Hopkins Clinical Trials Unit, Pune, India
| | - Nikhil Gupte
- 3 Byramjee Jeejeebhoy Government Medical College-Johns Hopkins Clinical Trials Unit, Pune, India.,4 Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Samir Joshi
- 5 Byramjee Jeejeebhoy Government Medical College/Sassoon General Hospital, Pune, India
| | - Ajay Chandanwale
- 5 Byramjee Jeejeebhoy Government Medical College/Sassoon General Hospital, Pune, India
| | - Kathryn M Dupnik
- 1 Center for Global Health, Division of Infectious Diseases, Weill Cornell Medical College, New York, New York
| | - Vandana Kulkarni
- 3 Byramjee Jeejeebhoy Government Medical College-Johns Hopkins Clinical Trials Unit, Pune, India
| | - Prasad Deshpande
- 3 Byramjee Jeejeebhoy Government Medical College-Johns Hopkins Clinical Trials Unit, Pune, India
| | - Daniel W Fitzgerald
- 1 Center for Global Health, Division of Infectious Diseases, Weill Cornell Medical College, New York, New York
| | - Amita Gupta
- 3 Byramjee Jeejeebhoy Government Medical College-Johns Hopkins Clinical Trials Unit, Pune, India.,4 Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
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Cardona PJ. What We Have Learned and What We Have Missed in Tuberculosis Pathophysiology for a New Vaccine Design: Searching for the "Pink Swan". Front Immunol 2017; 8:556. [PMID: 28555137 PMCID: PMC5430026 DOI: 10.3389/fimmu.2017.00556] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 04/25/2017] [Indexed: 12/17/2022] Open
Abstract
This is a call to encourage the search for a new vaccine to stop the progression of Mycobacterium tuberculosis infection to tuberculosis (TB) disease. TB is a highly discreet and stigmatized disease, with a massive impact on human health. It has killed 1.2 billion people in the last 200 years and still kills 1.5 million people per year. Over the last 20 years, the TB vaccine field has experienced spectacular developments, and we have learned about (1) the importance of the Th1 response in controlling infection, mainly against RD1 and Ag85 antigens; (2) the stability of the antigenic repertoire; (3) the dynamics of M. tuberculosis granulomas; or (4) the link between typical and atypical pulmonary TB and the immune status of the host. However, we still do not (1) know how to avoid M. tuberculosis infection and reinfection; (2) understand the major role of the increase in lesion size in progression from infection to disease; (3) the role of interlobular septa in encapsulating pulmonary lesions; or (4) the role of neutrophilic infiltration and an exaggerated inflammatory response in the development of TB disease. These are strong reasons to pursue new, imaginative proposals involving both the antibody response and a balanced, tolerant immune response that averts progression toward TB. So far, the scientific mindset has been quite monolithic and has mainly focused on the stimulation of conventional T cells. But this approach has failed. For that reason, we are seeking unconventional perspectives to find a “pink swan,” a more efficacious and safer vaccine candidate.
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Affiliation(s)
- Pere-Joan Cardona
- Unitat de Tuberculosi Experimental, Institut Germans Trias i Pujol, Crta de Can Ruti s/n, Badalona, Catalonia, Spain
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La Manna MP, Orlando V, Dieli F, Di Carlo P, Cascio A, Cuzzi G, Palmieri F, Goletti D, Caccamo N. Quantitative and qualitative profiles of circulating monocytes may help identifying tuberculosis infection and disease stages. PLoS One 2017; 12:e0171358. [PMID: 28208160 PMCID: PMC5313257 DOI: 10.1371/journal.pone.0171358] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 01/19/2017] [Indexed: 01/31/2023] Open
Abstract
Tuberculosis (TB) is one of the most important cause of morbidity and death among infectious diseases, and continuous efforts are needed to improve diagnostic tools and therapy. Previous published studies showed that the absolute cells number of monocytes or lymphocytes in peripheral blood or yet the ratio of monocytes to lymphocytes displayed the ability to predict the risk of active TB. In the present study we evaluated the ratio of monocytes to lymphocytes variation and we also analyzed the ex-vivo expression of CD64 on monocytes as tools to identify biomarkers for discriminating TB stages. Significant differences were found when the average ratio of monocytes to lymphocytes of active TB patients was compared with latent TB infection (LTBI) subjects, cured TB and healthy donors (HD). By the receiver operator characteristics (ROC) curve analysis the cut-off value of 0.285, allowed the discrimination of active TB from HD, with a sensitivity of 91.04% and a specificity of 93.55% (95% of confidence interval: 0.92-0.99). The ROC curve analysis comparing TB patients and LTBI groups, led to a sensitivity and the specificity of the assay of 85.07% and 85.71%, respectively (95% of confidence interval: 0.85 to 0.96). The upregulation of CD64 expression on circulating monocytes in active TB patients could represent an additional biomarker for diagnosis of active TB. In conclusion, we found that the ML ratio or monocyte absolute count or phenotypic measures show predictive value for active TB.
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Affiliation(s)
- Marco Pio La Manna
- Central Laboratory of Advanced Diagnosis and Biomedical Research(CLADIBIOR), Azienda Universitaria Ospedaliera Policlinico P. Giaccone, Palermo, Italy
| | - Valentina Orlando
- Central Laboratory of Advanced Diagnosis and Biomedical Research(CLADIBIOR), Azienda Universitaria Ospedaliera Policlinico P. Giaccone, Palermo, Italy
| | - Francesco Dieli
- Central Laboratory of Advanced Diagnosis and Biomedical Research(CLADIBIOR), Azienda Universitaria Ospedaliera Policlinico P. Giaccone, Palermo, Italy
- Dipartimento di Biopatologia e Biotecnologie Mediche, Università di Palermo, Palermo, Italy
| | - Paola Di Carlo
- Department of Sciences for Health Promotion and Mother-Child Care “G. D’Alessandro”, University of Palermo, Palermo, Italy
| | - Antonio Cascio
- Department of Sciences for Health Promotion and Mother-Child Care “G. D’Alessandro”, University of Palermo, Palermo, Italy
| | - Gilda Cuzzi
- Translational Research Unit, National Institute for Infectious Diseases L. Spallanzani, Rome, Italy
| | - Fabrizio Palmieri
- Translational Research Unit, National Institute for Infectious Diseases L. Spallanzani, Rome, Italy
| | - Delia Goletti
- Translational Research Unit, National Institute for Infectious Diseases L. Spallanzani, Rome, Italy
| | - Nadia Caccamo
- Central Laboratory of Advanced Diagnosis and Biomedical Research(CLADIBIOR), Azienda Universitaria Ospedaliera Policlinico P. Giaccone, Palermo, Italy
- Dipartimento di Biopatologia e Biotecnologie Mediche, Università di Palermo, Palermo, Italy
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Fletcher HA, Schrager L. TB vaccine development and the End TB Strategy: importance and current status. Trans R Soc Trop Med Hyg 2017; 110:212-8. [PMID: 27076508 PMCID: PMC4830404 DOI: 10.1093/trstmh/trw016] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 02/17/2016] [Indexed: 01/12/2023] Open
Abstract
TB is now the leading, global cause of death due to a single infectious microbe. To achieve the End TB vision of reducing TB by 90% by 2035 we will need new interventions. The objectives of this manuscript are to summarize the status of the clinical TB vaccine pipeline; to assess the challenges facing the TB development field; and to discuss some of the key strategies being embraced by the field to overcome these challenges. Currently, 8 of the 13 vaccines in clinical development are subunit vaccines; 6 of these contain or express either Ag85A or Ag85B proteins. A major challenge to TB vaccine development is the lack of diversity in both the antigens included in TB vaccines, and the immune responses elicited by TB vaccine candidates. Both will need to be expanded to maximise the potential for developing a successful candidate by 2025. Current research efforts are focused on broadening both antigen selection and the range of vaccine-mediated immune responses. Previous and ongoing TB vaccine efficacy trials have built capacity, generated high quality data on TB incidence and prevalence, and provided insight into immune correlates of risk of TB disease. These gains will enable the design of better TB vaccines and, importantly, move these vaccines into efficacy trials more rapidly and at a lower cost than was possible for previous TB vaccine candidates.
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Affiliation(s)
- Helen A Fletcher
- Immunology and Infection Department, London School of Hygiene & Tropical Medicine, UK, W1CE7HT
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Distinct Transcriptional and Anti-Mycobacterial Profiles of Peripheral Blood Monocytes Dependent on the Ratio of Monocytes: Lymphocytes. EBioMedicine 2016; 2:1619-26. [PMID: 26870787 PMCID: PMC4740301 DOI: 10.1016/j.ebiom.2015.09.027] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 09/04/2015] [Accepted: 09/15/2015] [Indexed: 01/03/2023] Open
Abstract
The ratio of monocytes and lymphocytes (ML ratio) in peripheral blood is associated with tuberculosis and malaria disease risk and cancer and cardiovascular disease outcomes. We studied anti-mycobacterial function and the transcriptome of monocytes in relation to the ML ratio. Mycobacterial growth inhibition assays of whole or sorted blood were performed and mycobacteria were enumerated by liquid culture. Transcriptomes of unstimulated CD14 + monocytes isolated by magnetic bead sorting were characterised by microarray. Transcript expression was tested for association with ML ratio calculated from leucocyte differential counts by linear regression. The ML ratio was associated with mycobacterial growth in vitro (β = 2.23, SE 0.91, p = 0.02). Using sorted monocytes and lymphocytes, in vivo ML ratio (% variance explained R2 = 11%, p = 0.02) dominated over in vitro ratios (R2 = 5%, p = 0.10) in explaining mycobacterial growth. Expression of 906 genes was associated with the ML ratio and 53 with monocyte count alone. ML-ratio associated genes were enriched for type-I and -II interferon signalling (p = 1.2 × 10− 8), and for genes under transcriptional control of IRF1, IRF2, RUNX1, RELA and ESRRB. The ML-ratio-associated gene set was enriched in TB disease (3.11-fold, 95% CI: 2.28–4.19, p = 5.7 × 10− 12) and other inflammatory diseases including atopy, HIV, IBD and SLE. The ML ratio is associated with distinct transcriptional and anti-mycobacterial profiles of monocytes that may explain the disease associations of the ML ratio. A pathophysiological basis for involvement of the ML ratio in infectious, malignant and cardiovascular diseases is unclear. Monocytes from individuals with high ML ratio have impaired control of mycobacterial growth and a distinctive transcriptome. These monocytes are characterised by enhanced interferon signalling, and intermediate transcription factors. The ML-ratio associated transcript signature is enriched in TB and other diseases including atopy, IBD and SLE. Ontogeny-specific function of monocytes may be the possible mechanism for the prognostic value of the ML ratio.
Enumeration of the absolute count of white blood cell subsets is one of the most frequently performed tests in clinical practice. Recently, elevation in the monocytes:lymphocytes (ML) ratio was linked to increased risk of tuberculosis and malaria disease, and poorer outcomes for many cancers and cardiovascular diseases. We sought to understand the mechanism of these disease associations. We found that the ML ratio reflects the functional capacity of monocytes and that genes that are differentially expressed in monocytes from donors with a high ML ratio are similar to those in other diseases such as HIV and inflammatory bowel disease. Because a specific type of blood-making stem cell regulates the ML ratio, it is plausible that the ratio reflects monocyte function because it is a clue to different monocyte origins. Our findings offer a mechanism for the predictive value of the ML ratio that may help improve its clinical utility.
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Tuberculosis Case Finding in HIV-Infected Pregnant Women in Kenya Reveals Poor Performance of Symptom Screening and Rapid Diagnostic Tests. J Acquir Immune Defic Syndr 2016; 71:219-27. [PMID: 26334736 DOI: 10.1097/qai.0000000000000826] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Tuberculosis (TB) during pregnancy in HIV-infected women is associated with poor maternal and infant outcomes. There are limited data on TB prevalence, optimal TB screening, and performance of rapid diagnostics in pregnant HIV-infected women. METHODS We conducted a cross-sectional study among HIV-infected pregnant women seeking antenatal care in western Kenya. After a standardized questionnaire, sputum smear microscopy for acid-fast bacilli, mycobacterial liquid culture, GeneXpert MTB/RIF (Xpert), urine lipoarabinomannan, and tuberculin skin testing were performed. We determined prevalence and correlates of culture-confirmed pulmonary TB, and compared diagnostic performance of World Health Organization (WHO) symptom screening and rapid diagnostic tests to sputum culture. RESULTS Between July 2013 and July 2014, we enrolled 306 women. Among 288 women with a valid sputum culture result, 54% were on antiretroviral treatment, median CD4 cell count was 437 cell per cubic millimeter (IQR 342-565), and prevalence of culture-confirmed pulmonary TB was 2.4% (confidence interval: 1.0% to 4.9%). Cough >2 weeks (P = 0.04) and positive tuberculin skin testing (≥ 5 mm, P = 0.03) were associated with pulmonary TB. Women with TB were 23-fold (95% confidence interval: 4.4 to 116.6) more likely to report a household member with TB symptoms (P = 0.002). WHO symptom screen (43%), acid-fast bacilli smear (0%), Xpert (43%), and lipoarabinomannan (0%) had low sensitivity but high specificity (81%, 99%, 99%, and 95%, respectively) for pulmonary TB. CONCLUSIONS HIV-infected pregnant women had appreciable prevalence of pulmonary TB despite modest immunosuppression. Current TB screening and diagnostic tools perform poorly in pregnant HIV-infected women. Adapted TB screening tools that include household member TB symptoms may be useful in this population.
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Fletcher HA, Filali-Mouhim A, Nemes E, Hawkridge A, Keyser A, Njikan S, Hatherill M, Scriba TJ, Abel B, Kagina BM, Veldsman A, Agudelo NM, Kaplan G, Hussey GD, Sekaly RP, Hanekom WA. Human newborn bacille Calmette-Guérin vaccination and risk of tuberculosis disease: a case-control study. BMC Med 2016; 14:76. [PMID: 27183822 PMCID: PMC4869393 DOI: 10.1186/s12916-016-0617-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 04/23/2016] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND An incomplete understanding of the immunological mechanisms underlying protection against tuberculosis (TB) hampers the development of new vaccines against TB. We aimed to define host correlates of prospective risk of TB disease following bacille Calmette-Guérin (BCG) vaccination. METHODS In this study, 5,726 infants vaccinated with BCG at birth were enrolled. Host responses in blood collected at 10 weeks of age were compared between infants who developed pulmonary TB disease during 2 years of follow-up (cases) and those who remained healthy (controls). RESULTS Comprehensive gene expression and cellular and soluble marker analysis failed to identify a correlate of risk. We showed that distinct host responses after BCG vaccination may be the reason: two major clusters of gene expression, with different myeloid and lymphoid activation and inflammatory patterns, were evident when all infants were examined together. Cases from each cluster demonstrated distinct patterns of gene expression, which were confirmed by cellular assays. CONCLUSIONS Distinct patterns of host responses to Mycobacterium bovis BCG suggest that novel TB vaccines may also elicit distinct patterns of host responses. This diversity should be considered in future TB vaccine development.
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Affiliation(s)
| | - Ali Filali-Mouhim
- Department of Pathology, Case Western Reserve University, Cleveland, OH, USA
| | - Elisa Nemes
- South African Tuberculosis Vaccine Initiative (SATVI), Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Anthony Hawkridge
- South African Tuberculosis Vaccine Initiative (SATVI), Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Alana Keyser
- South African Tuberculosis Vaccine Initiative (SATVI), Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Samuel Njikan
- South African Tuberculosis Vaccine Initiative (SATVI), Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Mark Hatherill
- South African Tuberculosis Vaccine Initiative (SATVI), Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Thomas J Scriba
- South African Tuberculosis Vaccine Initiative (SATVI), Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Brian Abel
- South African Tuberculosis Vaccine Initiative (SATVI), Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Benjamin M Kagina
- South African Tuberculosis Vaccine Initiative (SATVI), Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Ashley Veldsman
- South African Tuberculosis Vaccine Initiative (SATVI), Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Nancy Marín Agudelo
- Grupo de Inmunología Celular e Inmunogenética, Sede de Investigación Universitaria, Universidad de Antioquia, Medellín, Colombia
| | - Gilla Kaplan
- Public Health Research Institute, Rutgers Biomedical and Health Sciences, Newark, NJ, USA
| | - Gregory D Hussey
- South African Tuberculosis Vaccine Initiative (SATVI), Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | | | - Willem A Hanekom
- South African Tuberculosis Vaccine Initiative (SATVI), Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa.
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Reeme AE, Robinson RT. Dietary Vitamin D3 Suppresses Pulmonary Immunopathology Associated with Late-Stage Tuberculosis in C3HeB/FeJ Mice. THE JOURNAL OF IMMUNOLOGY 2016; 196:1293-304. [PMID: 26729807 DOI: 10.4049/jimmunol.1500931] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 11/29/2015] [Indexed: 12/18/2022]
Abstract
Tuberculosis (TB) is a significant human disease caused by inhalation of Mycobacterium tuberculosis. Left untreated, TB mortality is associated with a failure to resolve pulmonary immunopathology. There is currently widespread interest in using vitamin D3 (VitD3) as an adjunct therapy for TB because numerous in vitro studies have shown that VitD3 has direct and indirect mycobactericidal activities. However, to date, there have been no in vivo studies addressing whether VitD3 affects experimental TB outcome. In this study, we used C3HeB/FeJ mice to determine whether dietary VitD3 influences the outcome of experimental TB. We observed that although M. tuberculosis burdens did not differ between mice on a VitD3-replete diet (VitD(HI) mice) and mice on a VitD3-deficient diet (VitD(LO) mice), the inflammatory response in VitD(HI) mice was significantly attenuated relative to VitD(LO) controls. Specifically, the expression of multiple inflammatory pathways was reduced in the lungs at later disease stages as were splenocyte IL12/23p40 and IFN-γ levels following ex vivo restimulation. Dietary VitD3 also suppressed the accumulation of T cells in the mediastinal lymph nodes and lung granulomatous regions while concomitantly accelerating the accumulation of F4/80(+) and Ly6C/Ly6G(+) lineages. The altered inflammatory profile of VitD(HI) mice also associated with reductions in pulmonary immunopathology. VitD receptor-deficient (vdr(-/-)) radiation bone marrow chimeras demonstrate that reductions in pulmonary TB immunopathology are dependent on hematopoietic VitD responsiveness. Collectively, our data support a model wherein the in vivo role of VitD3 during TB is not to promote M. tuberculosis killing but rather to function through hematopoietic cells to reduce M. tuberculosis-elicited immunopathology.
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Affiliation(s)
- Allison E Reeme
- Department of Microbiology and Molecular Genetics, Medical College of Wisconsin, Milwaukee, WI 53226
| | - Richard T Robinson
- Department of Microbiology and Molecular Genetics, Medical College of Wisconsin, Milwaukee, WI 53226
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Individual-level factors associated with variation in mycobacterial-specific immune response: Gender and previous BCG vaccination status. Tuberculosis (Edinb) 2016; 96:37-43. [DOI: 10.1016/j.tube.2015.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 10/01/2015] [Accepted: 10/06/2015] [Indexed: 12/30/2022]
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Rakotosamimanana N, Richard V, Raharimanga V, Gicquel B, Doherty TM, Zumla A, Rasolofo Razanamparany V. Biomarkers for risk of developing active tuberculosis in contacts of TB patients: a prospective cohort study. Eur Respir J 2015; 46:1095-103. [PMID: 26250497 DOI: 10.1183/13993003.00263-2015] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 06/07/2015] [Indexed: 12/24/2022]
Abstract
Identifying those Mycobacterium tuberculosis latent-infected individuals most at risk of developing active tuberculosis (TB) using routine clinical and laboratory tests remains a huge challenge in TB control efforts. We conducted a prospective longitudinal study of clinical and laboratory markers associated with the risk of developing active TB in contacts with latent M. tuberculosis infection.HIV-negative household contacts (n=296) of pulmonary TB patients underwent monitoring of clinical features, full blood cell counts, tuberculin skin text (TST) and chest radiography performed regularly during 18 months of follow-up. Paired statistical tests, a Kaplan-Meier analysis and Cox proportional hazard modelling were performed on variables between contacts progressing or not progressing to active TB.The appearance of TB disease symptoms in contacts was significantly associated with an elevated peripheral percentage of blood monocytes (adjusted hazard ratio (aHR) 6.25, 95% CI 1.63-23.95; p<0.01), a ≥14 mm TST response (aHR 5.72, 95% CI 1.22-26.80; p=0.03) and an increased monocyte:lymphocyte ratio (aHR 4.97, 95% CI 1.3-18.99; p=0.03). Among contacts having TST ≥14 mm, a strong association with risk of progression to TB was found with an elevated blood monocyte percentage (aHR 8.46, 95% CI 1.74-41.22; p<0.01).Elevated percentage of peripheral blood monocytes plus an elevated TST response are potential biomarkers for identifying contacts of TB patients at highest risk of developing active TB.
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Affiliation(s)
| | - Vincent Richard
- Unité d'Epidémiologie, Institut Pasteur de Madagascar, Antananarivo, Madagascar Unité d'Epidémiologie, Institut Pasteur de Dakar, Dakar, Sénégal
| | | | - Brigitte Gicquel
- Unité de Génétique Mycobactérienne, Institut Pasteur Paris, Paris, France
| | - T Mark Doherty
- Staten Serum Institut, Copenhagen, Denmark GlaxoSmithKline, Copenhagen, Denmark
| | - Alimuddin Zumla
- Division of Infection and Immunity, University College London (UCL) and National Institute for Health Research Biomedical Research Centre, UCL Hospital, London, UK The University of Zambia-University College London Medical School (UNZA-UCLMS) Research and Training Project, University Teaching Hospital, Lusaka, Zambia
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