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Zhuang L, Yang L, Li L, Ye Z, Gong W. Mycobacterium tuberculosis: immune response, biomarkers, and therapeutic intervention. MedComm (Beijing) 2024; 5:e419. [PMID: 38188605 PMCID: PMC10771061 DOI: 10.1002/mco2.419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 10/03/2023] [Accepted: 10/12/2023] [Indexed: 01/09/2024] Open
Abstract
Although tuberculosis (TB) is an infectious disease, the progression of the disease following Mycobacterium tuberculosis (MTB) infection is closely associated with the host's immune response. In this review, a comprehensive analysis of TB prevention, diagnosis, and treatment was conducted from an immunological perspective. First, we delved into the host's immune response mechanisms against MTB infection as well as the immune evasion mechanisms of the bacteria. Addressing the challenges currently faced in TB diagnosis and treatment, we also emphasized the importance of protein, genetic, and immunological biomarkers, aiming to provide new insights for early and personalized diagnosis and treatment of TB. Building upon this foundation, we further discussed intervention strategies involving chemical and immunological treatments for the increasingly critical issue of drug-resistant TB and other forms of TB. Finally, we summarized TB prevention, diagnosis, and treatment challenges and put forward future perspectives. Overall, these findings provide valuable insights into the immunological aspects of TB and offer new directions toward achieving the WHO's goal of eradicating TB by 2035.
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Affiliation(s)
- Li Zhuang
- Beijing Key Laboratory of New Techniques of Tuberculosis Diagnosis and TreatmentSenior Department of Tuberculosis, the Eighth Medical Center of PLA General HospitalBeijingChina
- Senior Department of TuberculosisHebei North UniversityZhangjiakouHebeiChina
| | - Ling Yang
- Senior Department of TuberculosisHebei North UniversityZhangjiakouHebeiChina
| | - Linsheng Li
- Senior Department of TuberculosisHebei North UniversityZhangjiakouHebeiChina
| | - Zhaoyang Ye
- Senior Department of TuberculosisHebei North UniversityZhangjiakouHebeiChina
| | - Wenping Gong
- Beijing Key Laboratory of New Techniques of Tuberculosis Diagnosis and TreatmentSenior Department of Tuberculosis, the Eighth Medical Center of PLA General HospitalBeijingChina
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2
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Liu Y, Che G, Liu Y, Xu K. Tuberculosis mimicking the onset of systemic lupus erythematosus flare: Case based review. Int J Rheum Dis 2023. [PMID: 36724496 DOI: 10.1111/1756-185x.14585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/27/2022] [Accepted: 01/16/2023] [Indexed: 02/03/2023]
Abstract
AIM To analyze the clinical features of lupus-like tuberculosis (TB). METHODS Three cases of TB imitating systemic lupus erythematosus (SLE) flare were collected in our hospital. Based on literature review, there are only 3 reports of TB resembling lupus flare rather than SLE per se. RESULTS The 3 cases of lupus mimickers, with a mean age of 30.3 years, ranging from 27 to 32 years, had atypical features of SLE, namely no typical butterfly erythema, lupus hair, alopecia or proteinuria, similar to the patients reported in the 3 previously mentioned studies. Emergence of different autoantibodies like anti-nuclear antibodies, anti-double-stranded DNA, anti-nucleosome antibodies, and anti-histone antibodies could occur in TB, mostly as an epiphenomenon. In patients with specific serological anti-Sm and hypocomplementemia, active TB cannot be easily ruled out. The presence of autoantibodies neither altered the clinical manifestations and radiographic findings of active TB, nor were detectable after infections are resolved. The resistance of the SLE manifestations to the steroid and immunosuppressive treatment suggests the contribution of an infectious disease. CONCLUSION TB stimulated the production of autoantibodies, with shared affinity for mycobacteria and human antigens, which may have led to lupus mimickers.
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Affiliation(s)
- Yang Liu
- Department of Rheumatology and Immunology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China.,Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guozhu Che
- Department of Rheumatology and Immunology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China.,Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ying Liu
- Department of Rheumatology and Immunology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China.,Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ke Xu
- Department of Rheumatology and Immunology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China.,Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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3
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Benabdessalem C, Ouni R, Hamouda WB, Bettaieb J, Fathallah DM, Barbouche MR. Culture filtrate protein 32 as a potential target to attenuate the heterogeneous antibody response against Mycobacterium tuberculosis Antigens in different endemic settings. Int J Mycobacteriol 2022; 11:378-383. [PMID: 36510921 DOI: 10.4103/ijmy.ijmy_127_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background We previously reported the development of an enzyme-linked immunosorbent assay for the detection of the immunoglobulin G (IgG) response to Mycobacterium tuberculosis virulence factor - culture filtrate protein 32 (CFP32). The assay achieved high performance in comparing healthy Bacillus Calmette-Guerin-vaccinated controls with active tuberculosis (TB) patients from the Tunisian population. Herein, we aimed to assess the anti-CFP32 IgG response in suspected or confirmed active pulmonary TB individuals in different endemic settings. Methods Serum samples were obtained from 224 donors from African and Latin American countries with variable levels of TB endemicity and different ethnical origins. Receiver operating characteristic curve was used to evaluate the performance of the serological assay. Results The area under the curve was 0.70. The use of a cutoff level of 0.65 gave 67% and 68% sensitivity and specificity, respectively, regardless of ethnicity and endemicity. Except for the suspected Latin American group, overall multiple comparisons of medians pointed out the stability of the anti-CFP32 IgG response across the different endemic settings. Therefore, endemicity and ethnicity seem not to affect anti-CFP32 IgG response, mainly for detecting confirmed active TB individuals. Conclusions These findings suggest that the inclusion of CFP32 epitopes in multi-antigen TB assay could attenuate serological differences related to heterogeneous endemicity and ethnicity. For this purpose, we further identified B-cell epitopes belonging to CFP32 by an in silico analysis.
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Affiliation(s)
- Chaouki Benabdessalem
- Department of Immunology, Laboratory of Transmission, Control and Immunobiology of Infection, Institut Pasteur de Tunis; Department of Immunology, University Tunis El Manar, Tunis, Tunisia
| | - Rym Ouni
- Department of Immunology, Laboratory of Transmission, Control and Immunobiology of Infection, Institut Pasteur de Tunis; Department of Immunology, University Tunis El Manar, Tunis, Tunisia
| | - Wafa Ben Hamouda
- Department of Immunology, Laboratory of Transmission, Control and Immunobiology of Infection, Institut Pasteur de Tunis; Department of Immunology, University Tunis El Manar, Tunis, Tunisia
| | - Jihene Bettaieb
- Department of Immunology, Laboratory of Transmission, Control and Immunobiology of Infection, Institut Pasteur de Tunis; Department of Immunology, University Tunis El Manar, Tunis, Tunisia
| | - Dahmani Mohamed Fathallah
- Department of Immunology, Laboratory of Transmission, Control and Immunobiology of Infection, Institut Pasteur de Tunis, Tunis, Tunisia; Department of Life Sciences, Health Biotechnology Program, College of Graduate Studies, Arabian Gulf University, Manama, Kingdom of Bahrain
| | - Mohamed-Ridha Barbouche
- Department of Immunology, Laboratory of Transmission, Control and Immunobiology of Infection, Institut Pasteur de Tunis; Department of Immunology, University Tunis El Manar, Tunis, Tunisia
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4
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Flores J, Cancino JC, Chavez-Galan L. Lipoarabinomannan as a Point-of-Care Assay for Diagnosis of Tuberculosis: How Far Are We to Use It? Front Microbiol 2021; 12:638047. [PMID: 33935997 PMCID: PMC8081860 DOI: 10.3389/fmicb.2021.638047] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/22/2021] [Indexed: 12/13/2022] Open
Abstract
Tuberculosis (TB) is still a severe public health problem; the current diagnostic tests have limitations that delay treatment onset. Lipoarabinomannan (LAM) is a glycolipid that is a component of the cell wall of the bacillus Mycobacterium tuberculosis, the etiologic agent of TB. This glycolipid is excreted as a soluble form in urine. The World Health Organization has established that the design of new TB diagnostic methods is one of the priorities within the EndTB Strategy. LAM has been suggested as a biomarker to develop diagnostic tests based on its identification in urine, and it is one of the most prominent candidates to develop point-of-care diagnostic test because urine samples can be easily collected. Moreover, LAM can regulate the immune response in the host and can be found in the serum of TB patients, where it probably affects a wide variety of host cell populations, consequently influencing the quality of both innate and adaptive immune responses during TB infection. Here, we revised the evidence that supports that LAM could be used as a tool for the development of new point-of-care tests for TB diagnosis, and we discussed the mechanisms that could contribute to the low sensitivity of diagnostic testing.
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Affiliation(s)
- Julio Flores
- Laboratory of Integrative Immunology, Instituto Nacional de Enfermedades Respiratorias Ismael Cosio Villegas, Mexico City, Mexico.,Laboratory of Immunomicrobiology, Department of Microbiology, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Mexico City, Mexico
| | - Juan Carlos Cancino
- Laboratory of Immunomicrobiology, Department of Microbiology, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Mexico City, Mexico
| | - Leslie Chavez-Galan
- Laboratory of Integrative Immunology, Instituto Nacional de Enfermedades Respiratorias Ismael Cosio Villegas, Mexico City, Mexico
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5
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Abstract
TB is the leading cause of death from a single infectious agent globally, followed by HIV. Furthermore, TB represents the leading cause of death among people with HIV. HIV is known to cause severe defects in T cell immunity, rendering HIV/TB-coinfected individuals more susceptible to TB disease progression and complicating accurate TB disease diagnosis. Here, we demonstrate that HIV infection is additionally associated with severely compromised antibody responses, particularly in individuals with active TB. Moreover, despite the influence of HIV infection, antibody profiles still allow accurate classification of individuals with active versus latent TB. These findings reveal novel immunologic challenges associated with HIV/TB coinfection and additionally provide a basis with which to leverage the key antibody features identified to potentially combat TB globally via next-generation therapeutic or diagnostic design. Tuberculosis (TB) represents the largest cause of death in human immunodeficiency virus (HIV)-infected individuals in part due to HIV-related CD4+ T cell loss, rendering patients immunocompromised and susceptible to a loss of Mycobacterium tuberculosis control. However, in light of increasing data pointing to a role for humoral immunity in controlling M. tuberculosis infection, here, we aimed to define whether HIV infection also alters the humoral immune response in subjects with active and latent TB. We show that in the setting of active TB, HIV-positive individuals have significantly lower IgG responses to LAM and Ag85 than HIV-negative individuals. Furthermore, significant isotype/subclass-specific differences were frequently observed, with active TB, HIV-positive individuals demonstrating compromised antigen-specific IgM titers. HIV-infected individuals with active TB also exhibited a significant loss of influenza hemagglutinin- and tetanus toxoid-specific antibody titers at the isotype/subclass level, a symptom of broad humoral immune dysfunction likely precipitated by HIV infection. Finally, we illustrated that despite the influence of HIV infection, differences in M. tuberculosis-specific antibody profiles persist between latent and active TB disease. Taken together, these findings reveal significant HIV-associated disruptions of the humoral immune response in HIV/TB-coinfected individuals. IMPORTANCE TB is the leading cause of death from a single infectious agent globally, followed by HIV. Furthermore, TB represents the leading cause of death among people with HIV. HIV is known to cause severe defects in T cell immunity, rendering HIV/TB-coinfected individuals more susceptible to TB disease progression and complicating accurate TB disease diagnosis. Here, we demonstrate that HIV infection is additionally associated with severely compromised antibody responses, particularly in individuals with active TB. Moreover, despite the influence of HIV infection, antibody profiles still allow accurate classification of individuals with active versus latent TB. These findings reveal novel immunologic challenges associated with HIV/TB coinfection and additionally provide a basis with which to leverage the key antibody features identified to potentially combat TB globally via next-generation therapeutic or diagnostic design.
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6
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Koets AP, van den Esker MH, Riepema K, Bakker D. The Role of Phosphatidylinositol Mannosides in the Serological Diagnosis of Mycobacterial Infections. Vet Sci 2019; 6:E91. [PMID: 31766256 PMCID: PMC6958488 DOI: 10.3390/vetsci6040091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/04/2019] [Accepted: 11/08/2019] [Indexed: 11/16/2022] Open
Abstract
Accurate diagnosis of mycobacterial infections, such as bovine tuberculosis and paratuberculosis, remains challenging. Available direct diagnostic tests aimed at detecting the pathogen are highly specific but lack sensitivity, depending on the stage of infection and the prevalence of infection in a population. The sensitivity of indirect diagnostic assays that measure the host immune response to infection is similarly affected by disease characteristics. The choice of antigen used to detect a host response to infection has a critical impact on test sensitivity and specificity. Many indirect tests rely on crude antigen preparations and cell-free extracts, of which the production is poorly standardized. Moreover, these preparations contain ample uncharacterized cross-reactive compounds. To enhance serological test specificity, existing assays depend on the pre-treatment of samples and a relatively high cut-off value, that in turn influences test sensitivity. Research therefore focuses on the identification of more specific, defined antigens to improve diagnostics. In the current study, we extracted phosphatidylinositol mannosides (PIMs) and investigated their potential use in antibody-based tests. Our results demonstrate that specific IgG class antibodies are generated against PIMs in cows, but this is unrelated to tuberculosis or paratuberculosis infection status, making these antigens unsuitable for diagnostic applications. In addition, we demonstrate that PIMs are widely present in crude antigen preparations and in serum pre-absorption buffer. Our results indicate that PIMs are cross-reactive compounds with immunodominant B cell epitopes that could impair serological test specificity.
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Affiliation(s)
- Ad P. Koets
- Department of Bacteriology and Epidemiology, Wageningen Bioveterinary Research, Houtribweg 398221 RA Lelystad, The Netherlands; (M.H.v.d.E.); (K.R.)
- Department of Farm Animal Health, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 73584 CL Utrecht, The Netherlands
| | - Marielle H. van den Esker
- Department of Bacteriology and Epidemiology, Wageningen Bioveterinary Research, Houtribweg 398221 RA Lelystad, The Netherlands; (M.H.v.d.E.); (K.R.)
| | - Karel Riepema
- Department of Bacteriology and Epidemiology, Wageningen Bioveterinary Research, Houtribweg 398221 RA Lelystad, The Netherlands; (M.H.v.d.E.); (K.R.)
| | - Douwe Bakker
- Independent Researcher, 8212 AM Lelystad, The Netherlands;
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7
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Maekura R, Kitada S, Osada-Oka M, Tateishi Y, Ozeki Y, Fujicawa T, Miki M, Jyunnko O, Mori M, Matsumoto S. Serum antibody profiles in individuals with latent Mycobacterium tuberculosis infection. Microbiol Immunol 2019; 63:130-138. [PMID: 30851131 PMCID: PMC6767593 DOI: 10.1111/1348-0421.12674] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 02/21/2019] [Accepted: 03/05/2019] [Indexed: 11/26/2022]
Abstract
One-third of the world's humans has latent tuberculosis infection (LTBI), representing a large pool of potentially active TB. Recent LTBI carries a higher risk of disease progression than remote LTBI. Recent studies suggest important roles of antibodies in TB pathology, prompting us to investigate serum antibody profiles in a cohort with LTBI. In this single-center prospective observational study, we analyzed IgG-antibody concentrations against five major Mycobacterium tuberculosis (Mtb) antigens (including 6 kDa early secretory antigenic target (ESAT6), CFP10, and antigen 85A, which are expressed mainly in the growth phase; and mycobacterial DNA-binding protein 1 (MDP1) and alpha-crystallin like protein (Acr), which are expressed in the dormant phases) in individuals with recent (n=13) or remote (n=12) LTBI, no Mtb infection (n=19), or active TB (n=15). Antibody titers against ESAT6 and MDP1 were significantly higher in individuals with recent LTBI than in those with no Mtb infection or remote LTBI. All pairwise antibody titers against these five major antigens were significantly correlated throughout the stages of Mtb infection. Five individuals with recent LTBI had significantly higher antibody titers against ESAT6 (P = 0.03), Ag85A (P = 0.048), Acr (P = 0.057), and MDP1 (P = 0.0001) than in individuals with remote LTBI; they were also outside the normal range (+2 SDs). One of these individuals was diagnosed with active pulmonary TB at 18-month follow-up examination. These findings indicated that concentrations of antibodies against both multiplying and dormant Mtb are higher in recent LTBI and that individuals with markedly higher antibody titers may be appropriate candidates for prophylactic therapy.
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Affiliation(s)
- Ryoji Maekura
- Department of Respiratory Medicine, National Hospital Organization Toneyama National Hospital, Toyonaka, Osaka, Japan.,Graduate School of Health Care Sciences, Jikei Institute, Osaka, Japan
| | - Seigo Kitada
- Department of Respiratory Medicine, National Hospital Organization Toneyama National Hospital, Toyonaka, Osaka, Japan
| | - Mayuko Osada-Oka
- Food Hygiene and Environmental Health, Division of Applied Life Science, Graduate School of Life and Environmental Sciences, Kyoto Prefectural University, Kyoto, Japan
| | - Yoshitaka Tateishi
- Department of Bacteriology, Niigata University Graduate School of Medicine, Niigata, Japan
| | - Yuriko Ozeki
- Department of Bacteriology, Niigata University Graduate School of Medicine, Niigata, Japan
| | - Takeya Fujicawa
- Department of Respiratory Medicine, National Hospital Organization Toneyama National Hospital, Toyonaka, Osaka, Japan
| | - Mari Miki
- Department of Respiratory Medicine, National Hospital Organization Toneyama National Hospital, Toyonaka, Osaka, Japan
| | - Ogawa Jyunnko
- Department of Respiratory Medicine, National Hospital Organization Toneyama National Hospital, Toyonaka, Osaka, Japan
| | - Masahide Mori
- Department of Respiratory Medicine, National Hospital Organization Toneyama National Hospital, Toyonaka, Osaka, Japan
| | - Sohkichi Matsumoto
- Department of Bacteriology, Niigata University Graduate School of Medicine, Niigata, Japan
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8
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Longitudinal Evaluation of Humoral Immunity and Bacterial and Clinical Parameters Reveals That Antigen-Specific Antibodies Suppress Inflammatory Responses in Active Tuberculosis Patients. J Immunol Res 2018; 2018:4928757. [PMID: 30069487 PMCID: PMC6057312 DOI: 10.1155/2018/4928757] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 11/06/2017] [Accepted: 12/31/2017] [Indexed: 12/12/2022] Open
Abstract
A novel tuberculosis vaccine to replace BCG has long been desired. However, recent vaccine trials focused on cell-mediated immunity have failed to produce promising results. It is worth noting that most commercially available successful vaccines rely on humoral immunity. To establish a basic understanding of humoral immunity against tuberculosis, we analyzed and evaluated longitudinal levels and avidity of immunoglobulin to various tuberculosis antigens compared with bacterial and clinical parameters during treatment. We found that levels of IgG antibodies against HrpA and HBHA prior to treatment exhibited a positive correlation with bacterial burden. Analysis of changes in CRP during treatment revealed an association with high levels of specific IgG and IgA antibodies against mycobacterial antigens. Levels of CRP prior to treatment were negatively associated with IgG avidity to CFP-10 and MDP1 and IgA avidity to HrpA, while IgA avidity to MDP1 and Acr exhibited a negative correlation with CRP levels after 60 days of treatment. These results may provide insight for the development of a novel tuberculosis (TB) vaccine candidate to induce protective humoral immunity against tuberculosis.
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9
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Sun ET, Xia D, Li BH, Ma J, Dong YY, Ding SS, Chen BF, Wen YF. Association of Immune Factors with Drug-Resistant Tuberculosis: A Case-Control Study. Med Sci Monit 2017; 23:5330-5336. [PMID: 29118314 PMCID: PMC5691569 DOI: 10.12659/msm.904309] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background Presently, studies of factors associated with drug-resistant tuberculosis (TB) focus on patients’ socio-demographic characteristics and living habits, to the exclusion of biochemical indicators, especially immune factors. This study was carried out to determine whether immune factors are associated with drug-resistant TB. Material/Methods A total of 227 drug-resistant pulmonary TB patients and 225 drug-susceptible pulmonary TB patients were enrolled in this study. Information on socio-demographic characteristics and biochemical indicators were obtained through their clinical records. Non-conditional logistic regression was used to analyze the association of these indicators with drug-resistant TB. Results There were significant differences in re-treatment, marital status, alanine aminotransferase (ALT), blood uric acid (BUA), carcino-embryonic antigen (CEA), T-spot, and CD3 and CD4 counts between the 2 groups. In multivariable analysis, re-treatment [Odds Ratio (OR)=5.290, 95% Confidence Interval [CI]=2.652–10.551); CD3 (OR=1.034, 95% CI=1.001–1.068); CD4 (OR=1.035, 95% CI =1.001–1.070) and IgM (OR=1.845, 95% CI=1.153–2.952) were associated with drug-resistant TB. Conclusions These results suggest the need for greater attention to re-treatment cases and immune function when treating drug-resistant TB.
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Affiliation(s)
- En-Tao Sun
- School of Public Health, Wannan Medical College, Wuhu, Anhui, China (mainland)
| | - Dan Xia
- School of Public Health, Wannan Medical College, Wuhu, Anhui, China (mainland)
| | - Ben-He Li
- School of Public Health, Wannan Medical College, Wuhu, Anhui, China (mainland)
| | - Jun Ma
- School of Public Health, Wannan Medical College, Wuhu, Anhui, China (mainland)
| | - Yuan-Yuan Dong
- School of Public Health, Wannan Medical College, Wuhu, Anhui, China (mainland)
| | - Shu-Shu Ding
- School of Public Health, Wannan Medical College, Wuhu, Anhui, China (mainland)
| | - Bai-Feng Chen
- School of Public Health, Wannan Medical College, Wuhu, Anhui, China (mainland)
| | - Yu-Feng Wen
- School of Public Health, Wannan Medical College, Wuhu, Anhui, China (mainland)
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Luo L, Zhu L, Yue J, Liu J, Liu G, Zhang X, Wang H, Xu Y. Antigens Rv0310c and Rv1255c are promising novel biomarkers for the diagnosis of Mycobacterium tuberculosis infection. Emerg Microbes Infect 2017; 6:e64. [PMID: 28698665 PMCID: PMC5567170 DOI: 10.1038/emi.2017.54] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 05/21/2017] [Accepted: 05/22/2017] [Indexed: 12/19/2022]
Abstract
This study aimed to identify novel immunogenic epitopes from Mycobacterium tuberculosis (MTB) that could be used in tuberculosis (TB) diagnostics. To determine the diagnostic potential of mycobacterial antigens in serodiagnosis of TB, 256 patients were enrolled in a study and divided into two groups: 126 smear-positive pulmonary TB patients (SPPT) and 130 smear-negative pulmonary TB patients (SNPT); 152 bacillus Calmette-Guerin (BCG)-vaccinated healthy people were used as a control. Murine results showed that antigens Rv0310c-E from RD 8 and Rv1255c-E from RD 10 were strongly immunogenic to Th1 cells and induced a great humoral response. Receiver operating characteristic analysis indicated that Rv0310c-E (area under the curve (AUC): 0.800) and Rv1255c-E (AUC: 0.808) performed better than ESAT-6 (AUC: 0.665) and CFP-10 (AUC: 0.623) proteins but were comparable with Rv3425 (AUC: 0.788) protein in a human serum IgG analysis. Rv0310c-E demonstrated the highest diagnostic ability for the SPPT group (Youden index: 0.5602, sensitivity: 69.84%, specificity: 86.18%), while Rv1255c-E demonstrated the highest diagnostic ability for the SNPT group (Youden index: 0.5674, sensitivity: 73.84%, specificity: 82.89%). In addition, combination analysis found that antigen Rv0310c-E, coupled with the Rv3425 protein (Youden index: 0.6098, sensitivity: 87.30%, specificity: 73.68%) had the strongest performance for TB diagnostics of the SPPT group, and the single antigen Rv1255c-E was strongest for the SNPT group. These results suggest that antigens Rv0310c-E and Rv1255c-E are potential antigens for TB serodiagnostic tests, which may facilitate detection of MTB in smear-negative and smear-positive patients.
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Affiliation(s)
- Liulin Luo
- State Key Laboratory of Genetic Engineering, Institute of Genetics, Fudan University, Shanghai 200433, China.,Department of Clinical Laboratory Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Lin Zhu
- State Key Laboratory of Genetic Engineering, Institute of Genetics, Fudan University, Shanghai 200433, China
| | - Jun Yue
- Department of Clinical Laboratory Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Jianping Liu
- State Key Laboratory of Genetic Engineering, Institute of Genetics, Fudan University, Shanghai 200433, China
| | - Guoyuan Liu
- State Key Laboratory of Genetic Engineering, Institute of Genetics, Fudan University, Shanghai 200433, China
| | - Xuelian Zhang
- State Key Laboratory of Genetic Engineering, Institute of Genetics, Fudan University, Shanghai 200433, China
| | - Honghai Wang
- State Key Laboratory of Genetic Engineering, Institute of Genetics, Fudan University, Shanghai 200433, China
| | - Ying Xu
- State Key Laboratory of Genetic Engineering, Institute of Genetics, Fudan University, Shanghai 200433, China
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11
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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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12
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Zagmignan A, Costa ACD, Viana JL, Lima Neto LG, Monteiro CDA, Gaioso Neto AG, Junqueira-Kipnis AP, de Sousa EM. Identification of specific antibodies against the Ag85C-MPT51-HspX fusion protein (CMX) for serological screening of tuberculosis in endemic area. Expert Rev Clin Immunol 2017. [PMID: 28633546 DOI: 10.1080/1744666x.2017.1345626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Development of new tools for rapid and accurate diagnosis of tuberculosis (TB) is considered a strategy for controlling the disease. The recombinant CMX fusion protein is composed of immunodominant epitopes of the Ag85C (Rv0129c), MPT51 (Rv3803c) and the entire HspX (Rv2031c) proteins from Mycobacterium tuberculosis H37Rv (Mtb). The aim of this study was to evaluate the applicability of a test using the CMX protein in individuals suspected of TB. METHODS Indirect ELISA was used to measure serum anti-CMX IgM and IgG in individuals with pulmonary TB. RESULTS Patients with pulmonary TB had higher titers of IgM (OD = 0.502 ± 0.281) than healthy controls (OD = 0.200 ± 0.125). The cutoff for IgM-ELISA was determined using ROC curve analyzes (AUC = 0.868) with a sensitivity of 80.1% and a specificity of 78.2%. Patients with pulmonary TB also had higher titers of IgG (OD = 0.525 ± 0.391) than healthy controls (OD = 0.215 ± 0.077). The cutoff for IgG-ELISA was determined using ROC curve analyzes (AUC = 0.864) with a sensitivity of 81.7% and a specificity of 74.7%. CONCLUSION The results suggest that the recombinant protein CMX can be used in a serological test to complement the screening of individuals suspected of having active pulmonary TB.
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Affiliation(s)
- Adrielle Zagmignan
- a Programa de Pós-graduação , Universidade Ceuma , São Luis , MA , Brazil
| | - Adeliane Castro da Costa
- b Universidade Federal de Goias- Laboratory of Immunopathology of Infectious Disease, Department of Microbiology , Immunology, Parasitology and Pathology, Institute of Tropical Disease and Public Health , Goiania , Brazil
| | - José Lima Viana
- a Programa de Pós-graduação , Universidade Ceuma , São Luis , MA , Brazil
| | | | | | | | - Ana Paula Junqueira-Kipnis
- b Universidade Federal de Goias- Laboratory of Immunopathology of Infectious Disease, Department of Microbiology , Immunology, Parasitology and Pathology, Institute of Tropical Disease and Public Health , Goiania , Brazil
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You X, Li R, Wan K, Liu L, Xie X, Zhao L, Wu N, Deng X, Wang L, Zeng Y. Evaluation of Rv0220, Rv2958c, Rv2994 and Rv3347c of Mycobacterium tuberculosis for serodiagnosis of tuberculosis. Microb Biotechnol 2017; 10:604-611. [PMID: 28217905 PMCID: PMC5404193 DOI: 10.1111/1751-7915.12697] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 01/18/2017] [Indexed: 11/26/2022] Open
Abstract
Tuberculosis (TB), the leading cause of death among infectious diseases worldwide, is caused by Mycobacterium tuberculosis (M. tuberculosis). Early accurate diagnosis means earlier prevention, treatment and control of TB. To confirm efficient diagnostic antigens for M. tuberculosis, the serodiagnosis value of four recombinant proteins including Rv0220, Rv2958c, Rv2994 and Rv3347c was evaluated in this study. The specificities and sensitivities of four recombinant proteins were determined based on enzyme‐linked immunosorbent assay (ELISA) by screening sera from smear‐positive pulmonary TB patients (n = 92), uninfected individuals (n = 60) and patients with Mycoplasma pneumoniae (n = 32) that potentially cross‐react with M. tuberculosis. The ELISAs showed that Rv0220, Rv2958c, Rv2994 and Rv3347c exhibited high specificities and sensitivities in detecting immunoglobulin G (IgG) antibody, with 98.3/91.3%, 91.7/85.9%, 93.3/89.1% and 93.3/80.4% respectively. According to the receiver‐operating characteristic (ROC) analysis, the area under the ROC of the target proteins was 0.988, 0.969, 0.929 and 0.945 respectively. Western blot was established to evaluate the immunoreactivities of target proteins to mice and human sera. Results demonstrated that Rv0220, Rv2958c, Rv2994 and Rv3347c could specifically recognize TB‐positive sera and the sera of mice immunized with the corresponding protein. Thus, Rv0220, Rv2958c, Rv2994 and Rv3347c were valuable potential diagnostic antigens for M. tuberculosis.
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Affiliation(s)
- Xiaolong You
- Institute of Pathogenic Biology, Medical College, University of South China, Hengyang, 421001, China.,Hunan Provincial Key Laboratory for Special Pathogens Prevention and Control, Hengyang, 421001, China.,Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study, Hengyang, 421001, China.,Clinical laboratory, The First Affiliated Hospital of University of South China, Hengyang, 421000, China
| | - Ranhui Li
- Institute of Pathogenic Biology, Medical College, University of South China, Hengyang, 421001, China.,Hunan Provincial Key Laboratory for Special Pathogens Prevention and Control, Hengyang, 421001, China.,Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study, Hengyang, 421001, China
| | - Kanglin Wan
- State Key Laboratory for Infectious Disease Prevention and Control/National Institute for communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, 102206, China
| | - Liangzhuan Liu
- Institute of Pathogenic Biology, Medical College, University of South China, Hengyang, 421001, China.,Hunan Provincial Key Laboratory for Special Pathogens Prevention and Control, Hengyang, 421001, China.,Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study, Hengyang, 421001, China
| | - Xiaoping Xie
- Clinical laboratory, Hengyang No.1 People's Hospital, Hengyang, 421001, China
| | - Lanhua Zhao
- Institute of Pathogenic Biology, Medical College, University of South China, Hengyang, 421001, China.,Hunan Provincial Key Laboratory for Special Pathogens Prevention and Control, Hengyang, 421001, China.,Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study, Hengyang, 421001, China
| | - Ning Wu
- Clinical laboratory, The First Affiliated Hospital of University of South China, Hengyang, 421000, China
| | - Xiangying Deng
- Institute of Pathogenic Biology, Medical College, University of South China, Hengyang, 421001, China.,Hunan Provincial Key Laboratory for Special Pathogens Prevention and Control, Hengyang, 421001, China.,Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study, Hengyang, 421001, China
| | - Li Wang
- Institute of Pathogenic Biology, Medical College, University of South China, Hengyang, 421001, China.,Hunan Provincial Key Laboratory for Special Pathogens Prevention and Control, Hengyang, 421001, China.,Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study, Hengyang, 421001, China
| | - Yanhua Zeng
- Institute of Pathogenic Biology, Medical College, University of South China, Hengyang, 421001, China.,Hunan Provincial Key Laboratory for Special Pathogens Prevention and Control, Hengyang, 421001, China.,Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study, Hengyang, 421001, China
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14
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Difference in Antibody Responses to Mycobacterium tuberculosis Antigens in Japanese Tuberculosis Patients Infected with the Beijing/Non-Beijing Genotype. J Immunol Res 2017; 2017:4797856. [PMID: 28182078 PMCID: PMC5274661 DOI: 10.1155/2017/4797856] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 12/08/2016] [Indexed: 01/25/2023] Open
Abstract
The Beijing genotype Mycobacterium tuberculosis (MTB), notorious for its virulence and predisposition to relapse, could be identified by spoligotyping based on genetic heterogeneity. The plasma samples from 20 cases of Beijing and 16 cases of non-Beijing MTB infected individuals and 24 healthy controls (HCs) were collected, and antibodies against 11 antigens (Rv0679c142Asn, Rv0679c142Lys, Ag85B, Ag85A, ARC, TDM-M, TDM-K, HBHA, MDP-1, LAM, and TBGL) were measured by ELISA. Compared to the HCs, the MTB infected subjects showed higher titers of anti-Ag85B IgG (positivity 58.2%) and anti-ACR IgG (positivity 48.2%). Of note, anti-ACR IgG showed higher titer in Beijing MTB infected tuberculosis (TB) patients than in HC (Kruskal–Wallis test, p < 0.05), while the levels of anti-Ag85B, anti-TBGL, anti-TDM-K, and anti-TDM-M IgG were higher in non-Beijing TB patients than in HC. Moreover, anti-Ag85B IgG showed higher response in non-Beijing TB patients than in Beijing TB patients (p < 0.05; sensitivity, 76.9% versus 44.4%). The sensitivity and specificity analysis showed that 78.8% Beijing infected individuals were negative in anti-TBGL-IgG or/and anti-Ag85B-IgG, while 75.0% of those were positive in anti-TBGL-IgA or/and anti-ACR-IgG tests. These results indicate the possibility of developing antibody-based test to identify Beijing MTB.
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15
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Hur YG, Chung WY, Kim A, Kim YS, Kim HS, Jang SH, Kim Y, Lee H, Park KJ, Cho SN. Host immune responses to antigens derived from a predominant strain of Mycobacterium tuberculosis. J Infect 2016; 73:54-62. [PMID: 27155519 DOI: 10.1016/j.jinf.2016.04.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 04/27/2016] [Accepted: 04/28/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Beijing strain of Mycobacterium tuberculosis (M. tb) is characterized by a high incidence of transmission, relapse, and drug resistance. This study aimed to determine host immune responses to antigens derived from the Beijing/K strain which has been highly prevalent in tuberculosis (TB) outbreaks in South Korea. METHODS We recruited 52 TB patients and 96 healthy subjects comprising 31 individuals with latent TB infection (LTBI) and 65 TB-naïve controls based on QuantiFERON-TB Gold In-Tube (QFT-IT) tests. Blood samples were obtained for diluted whole-blood assays, multiplex bead arrays, ELISpot assays, and HLA typing. Molecular genotyping of M. tb was performed using clinical isolates. RESULTS Active TB and LTBI groups were differentiated by TNF-α concentrations induced by the Beijing/K strain-derived antigens, MTBK_24790 and MTBK_24800 (P < 0.001). MTBK_24800-induced IFN-γ and CXCL10 concentrations discriminated the TB-infected groups from TB-naïve controls (P < 0.001). IFN-γ-producing T cells were generated in 87.2% of TB patients in response to MTBK_24800 peptide antigens. The major immunogenic epitope was at C-terminal of the antigen, and predominantly recognized by HLA-DR4 and -DQ4. CONCLUSIONS Measurement of IFN-γ, CXCL10, and TNF-α concentrations induced by MTBK_24790 and MTBK_24800 may contribute to improved diagnosis of TB and vaccine development in regions where the Beijing/K strain is endemic.
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Affiliation(s)
- Yun-Gyoung Hur
- Department of Microbiology and Institute for Immunology and Immunological Diseases, Brain Korea 21 Plus Project for Medical Science, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Wou Young Chung
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, San 5, Wonchon-dong, Yeongtong-gu, Suwon 16499, Gyeonggi, Republic of Korea
| | - Ahreum Kim
- Department of Microbiology and Institute for Immunology and Immunological Diseases, Brain Korea 21 Plus Project for Medical Science, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Young Sun Kim
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, San 5, Wonchon-dong, Yeongtong-gu, Suwon 16499, Gyeonggi, Republic of Korea
| | - Hyon-Suk Kim
- Department of Laboratory Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Sun-Hee Jang
- Department of Microbiology and Institute for Immunology and Immunological Diseases, Brain Korea 21 Plus Project for Medical Science, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Yeun Kim
- Department of Biomedical Laboratory Science, College of Health Sciences, Yonsei University, Wonju 26493, Gangwon, Republic of Korea
| | - Hyeyoung Lee
- Department of Biomedical Laboratory Science, College of Health Sciences, Yonsei University, Wonju 26493, Gangwon, Republic of Korea
| | - Kwang Joo Park
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, San 5, Wonchon-dong, Yeongtong-gu, Suwon 16499, Gyeonggi, Republic of Korea.
| | - Sang-Nae Cho
- Department of Microbiology and Institute for Immunology and Immunological Diseases, Brain Korea 21 Plus Project for Medical Science, Yonsei University College of Medicine, Seoul 03722, Republic of Korea.
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16
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Single Nucleotide Polymorphisms in P2X7 Gene Are Associated with Serum Immunoglobulin G Responses to Mycobacterium tuberculosis in Tuberculosis Patients. DISEASE MARKERS 2015; 2015:671272. [PMID: 26798189 PMCID: PMC4698936 DOI: 10.1155/2015/671272] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 10/14/2015] [Accepted: 10/18/2015] [Indexed: 01/12/2023]
Abstract
Objective. Our study investigated the association between single nucleotide polymorphisms (SNPs) in P2X7 gene and serum immunoglobulin G (IgG) responses to mycobacterium tuberculosis (MTB) in TB patients. Methods. A total of 103 TB patients were enrolled as case group and 87 healthy individuals at same geographical region as control group. The SNP detection of 1513A>C and -762T>C was performed using PCR-RFLP, and the levels of serum IgG responses to MTB in all subjects were determined. Results. AC and CC of 1513A>C and TC and CC of -762T>C had higher frequencies in case group than in control group. TB patients carrying TC and CC of -762T>C had higher positive rate of IgG responses to MTB than those carrying TT. Additionally, patients carrying TC and CC of -762T>C had more MTB in sputum than those carrying TT. Conclusion. P2X7 SNPs, 1513A>C and -762T>C, may be associated with the susceptibility to tuberculosis, and -762T>C SNP may contribute to the development of MTB. The mutant genotype of -762T>C (TC and CC) may lower human capability of phagocytosis to MTB, leading to an increased morbidity of TB.
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Biraro IA, Egesa M, Kimuda S, Smith SG, Toulza F, Levin J, Joloba M, Katamba A, Cose S, Dockrell HM, Elliott AM. Effect of isoniazid preventive therapy on immune responses to mycobacterium tuberculosis: an open label randomised, controlled, exploratory study. BMC Infect Dis 2015; 15:438. [PMID: 26493989 PMCID: PMC4619204 DOI: 10.1186/s12879-015-1201-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 10/12/2015] [Indexed: 11/17/2022] Open
Abstract
Background With the renewed emphasis to implement isoniazid preventive therapy (IPT) in Sub-Saharan Africa, we investigated the effect of IPT on immunological profiles among household contacts with latent tuberculosis. Methods Household contacts of confirmed tuberculosis patients were tested for latent tuberculosis using the QuantiFERON®-TB Gold In-Tube (QFN) assay and tuberculin skin test (TST). HIV negative contacts aged above 5 years, positive to both QFN and TST, were randomly assigned to IPT and monthly visits or monthly visits only. QFN culture supernatants from enrolment and six months’ follow-up were analysed for M.tb-specific Th1, Th2, Th17, and regulatory cytokines by Luminex assay, and for M.tb-specific IgG antibody concentrations by ELISA. Effects of IPT were assessed as the net cytokine and antibody production at the end of six months. Results Sixteen percent of contacts investigated (47/291) were randomised to IPT (n = 24) or no IPT (n = 23). After adjusting for baseline cytokine or antibody responses, and for presence of a BCG scar, IPT (compared to no IPT) resulted in a relative decline in M.tb-specific production of IFN gamma (adjusted mean difference at the end of six months (bootstrap 95 % confidence interval (CI), p-value) -1488.6 pg/ml ((−2682.5, −294.8), p = 0.01), and IL- 2 (−213.1 pg/ml (−419.2, −7.0), p = 0.04). A similar decline was found in anti-CFP-10 antibody levels (adjusted geometric mean ratio (bootstrap 95 % CI), p-value) 0.58 ((0.35, 0.98), p = 0.04). We found no effect on M.tb-specific Th2 or regulatory or Th17 cytokine responses, or on antibody concentrations to PPD and ESAT-6. Conclusions IPT led to a decrease in Th1 cytokine production, and also in the anti CFP-10 antibody concentration. This could be secondary to a reduction in mycobacterial burden or as a possible direct effect of isoniazid induced T cell apoptosis, and may have implications for protective immunity following IPT in tuberculosis-endemic countries. Trial registration ISRCTN registry, ISRCTN15705625. Registered on 30th September 2015.
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Affiliation(s)
- Irene Andia Biraro
- Department of Internal Medicine, College of Health Sciences, Makerere University, P.O Box 7072, Kampala, Uganda.
| | - Moses Egesa
- Department of Internal Medicine, College of Health Sciences, Makerere University, P.O Box 7072, Kampala, Uganda.
| | - Simon Kimuda
- Department of Internal Medicine, College of Health Sciences, Makerere University, P.O Box 7072, Kampala, Uganda.
| | - Steven G Smith
- Department of Immunology and Infection, London School of Hygiene &Tropical Medicine, London, UK.
| | - Frederic Toulza
- Department of Immunology and Infection, London School of Hygiene &Tropical Medicine, London, UK.
| | - Jonathan Levin
- Medical Research Council/Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe, Uganda. .,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Moses Joloba
- Department of Internal Medicine, College of Health Sciences, Makerere University, P.O Box 7072, Kampala, Uganda.
| | - Achilles Katamba
- Department of Internal Medicine, College of Health Sciences, Makerere University, P.O Box 7072, Kampala, Uganda.
| | - Stephen Cose
- Medical Research Council/Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe, Uganda. .,Department of Clinical Research, London School of Hygiene &Tropical Medicine, London, UK.
| | - Hazel M Dockrell
- Department of Immunology and Infection, London School of Hygiene &Tropical Medicine, London, UK.
| | - Alison M Elliott
- Medical Research Council/Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe, Uganda. .,Department of Clinical Research, London School of Hygiene &Tropical Medicine, London, UK.
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