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Hermans SM, Akkerman OW, Meintjes G, Grobusch MP. Post-tuberculosis treatment paradoxical reactions. Infection 2024:10.1007/s15010-024-02310-0. [PMID: 38955990 DOI: 10.1007/s15010-024-02310-0] [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: 04/11/2024] [Accepted: 05/28/2024] [Indexed: 07/04/2024]
Abstract
Paradoxical reactions (PR) to tuberculosis (TB) treatment are common during treatment, but have also been described after treatment. A presentation with recurrent signs or symptoms of TB after cure or completion of prior treatment needs to be differentiated between microbiological relapse and a paradoxical reaction. We searched all published literature on post-treatment PR, and present a synthesis of 30 studies, focusing on the epidemiology, diagnosis and management of this phenomenon. We report an additional case vignette. The majority of studies were of lymph node TB (LN-TB), followed by central nervous system TB (CNS-TB). A total of 112 confirmed and 42 possible post-treatment PR cases were reported. The incidence ranged between 3 and 14% in LN-TB and was more frequent than relapses, and between 0 and 2% in all TB. We found four reports of pulmonary or pleural TB post-treatment PR cases. The incidence did not differ by length of treatment, but was associated with younger age at initial diagnosis, and having had a PR (later) during treatment. Post-treatment PR developed mainly within the first 6 months after the end of TB treatment but has been reported many years later (longest report 10 years). The mainstays of diagnosis and management are negative mycobacterial cultures and anti-inflammatory treatment, respectively. Due to the favourable prognosis in LN-TB recurrent symptoms, a short period of observation is warranted to assess for spontaneous regression. In CNS-TB with recurrent symptoms, immediate investigation and anti-inflammatory treatment with the possibility of TB retreatment should be undertaken.
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Affiliation(s)
- Sabine M Hermans
- Centre for Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam Public Health-Global Health, Amsterdam Infection and Immunity, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands.
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands.
| | - Onno W Akkerman
- Department of Pulmonary Diseases and Tuberculosis, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
- University Medical Centre Groningen, TB Centre Beatrixoord, University of Groningen, Groningen, The Netherlands
| | - Graeme Meintjes
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Blizard Institute, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Martin P Grobusch
- Centre for Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam Public Health-Global Health, Amsterdam Infection and Immunity, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Institute of Tropical Medicine, University of Tuebingen, Tübingen, Germany
- Centre de Recherches Médicales en Lambaréné (CERMEL), Lambaréné, Gabon
- Masanga Medical Research Unit (MMRU), Masanga, Sierra Leone
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Disseminated tuberculosis with paradoxical reactions caused by a Mycobacterium tuberculosis strain belonging to the Indo-Oceanic lineage: An imported case in Japan. J Infect Chemother 2022; 28:965-970. [DOI: 10.1016/j.jiac.2022.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/30/2021] [Accepted: 02/06/2022] [Indexed: 11/20/2022]
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Bell LCK, Breen R, Miller RF, Noursadeghi M, Lipman M. Paradoxical reactions and immune reconstitution inflammatory syndrome in tuberculosis. Int J Infect Dis 2016; 32:39-45. [PMID: 25809754 DOI: 10.1016/j.ijid.2014.12.030] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 12/15/2014] [Accepted: 12/16/2014] [Indexed: 12/01/2022] Open
Abstract
The coalescence of the HIV-1 and tuberculosis (TB) epidemics in Sub-Saharan Africa has had a significant and negative impact on global health. The availability of effective antimicrobial treatment for both HIV-1 (in the form of highly active antiretroviral therapy (HAART)) and TB (with antimycobacterial agents) has the potential to mitigate the associated morbidity and mortality. However, the use of both HAART and antimycobacterial therapy is associated with the development of inflammatory paradoxical syndromes after commencement of therapy. These include paradoxical reactions (PR) and immune reconstitution inflammatory syndromes (IRIS), conditions that complicate mycobacterial disease in HIV seronegative and seropositive individuals. Here, we discuss case definitions for PR and IRIS, and explore how advances in identifying the risk factors and immunopathogenesis of these conditions informs our understanding of their shared underlying pathogenesis. We propose that both PR and IRIS are characterized by the triggering of exaggerated inflammation in a setting of immunocompromise and antigen loading, via the reversal of immunosuppression by HAART and/or antimycobacterials. Further understanding of the molecular basis of this pathogenesis may pave the way for effective immunotherapies for the treatment of PR and IRIS.
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Affiliation(s)
- Lucy C K Bell
- Division of Infection and Immunity, Cruciform Building, University College London, Gower Street, London WC1E 6BT, UK.
| | - Ronan Breen
- Department of Respiratory Medicine, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Robert F Miller
- Research Department of Infection and Population Health, Institute of Epidemiology and Healthcare, University College London, London, UK
| | - Mahdad Noursadeghi
- Division of Infection and Immunity, Cruciform Building, University College London, Gower Street, London WC1E 6BT, UK
| | - Marc Lipman
- Centre for Respiratory Medicine, Royal Free London NHS Foundation Trust, University College London, London, UK
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Lawn SD, Meintjes G. Pathogenesis and prevention of immune reconstitution disease during antiretroviral therapy. Expert Rev Anti Infect Ther 2011; 9:415-30. [PMID: 21504399 DOI: 10.1586/eri.11.21] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The risks of unmasking and paradoxical forms of immune reconstitution disease in HIV-infected patients starting antiretroviral therapy (ART) are fuelled by a combination of the late presentation of patients with advanced immunodeficiency, the associated high rates of opportunistic infections (OIs) and the need for rapid initiation of ART to minimize overall mortality risk. We review the risk factors and our current knowledge of the immunopathogenesis of immune reconstitution disease, leading to a discussion of strategies for prevention. Initiation of ART at higher CD4 counts, use of OI-preventive therapies prior to ART eligibility, intensified screening for OIs prior to ART initiation and optimum therapy for OIs are all needed. In addition, use of a range of pharmacological agents with immunosuppressive and immunomodulatory activity is being explored.
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Affiliation(s)
- Stephen D Lawn
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
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Abstract
PURPOSE OF REVIEW We review immune reconstitution disease associated with mycobacterial infections in patients receiving antiretroviral treatment. We draw particular attention to data relevant to resource-limited settings and focus predominantly on publications over the past year. RECENT FINDINGS Worldwide mycobacteria are the most important group of pathogens associated with immune reconstitution disease. In cohorts of patients with tuberculosis in high-income countries, up to one-third develop immune reconstitution disease compared with only 8-13% in current reports from resource-limited settings. We speculate on potential explanations for this difference. While most cases of tuberculosis immune reconstitution disease are self-limiting, deaths have been reported in South African and Thai cohorts. We discuss how risk and outcomes of tuberculosis immune reconstitution disease represent key variables regarding the optimum time to initiate antiretroviral treatment in tuberculosis patients. A new conceptual framework has been proposed regarding 'unmasking' of tuberculosis during antiretroviral treatment. Increasing numbers of cases of leprosy immune reconstitution disease and Bacillus Calmette-Guérin immune reconstitution disease have also been reported, mainly from resource-limited settings. Immune reconstitution disease associated with a variety of mycobacteria (tuberculous and nontuberculous) was common in a cohort of Thai children. SUMMARY Immune reconstitution disease associated with a range of mycobacteria constitutes a challenge to delivery of antiretroviral treatment worldwide. Data concerning the pathogenesis and management of all forms of mycobacterial immune reconstitution disease are lacking.
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Fernández-Fúnez Á. Respuesta paradójica durante el tratamiento tuberculostático en pacientes inmunocompetentes. Med Clin (Barc) 2009; 133:637-43. [DOI: 10.1016/j.medcli.2008.12.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2008] [Accepted: 12/18/2008] [Indexed: 11/28/2022]
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Simonney N, Dewulf G, Herrmann JL, Gutierrez MC, Vicaut E, Boutron C, Leportier M, Lafaurie M, Abgrall S, Sereni D, Autran B, Carcelain G, Bourgarit A, Lagrange PH. Anti-PGL-Tb1 responses as an indicator of the immune restoration syndrome in HIV-TB patients. Tuberculosis (Edinb) 2008; 88:453-61. [PMID: 18495539 DOI: 10.1016/j.tube.2008.01.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2007] [Revised: 01/08/2008] [Accepted: 01/12/2008] [Indexed: 10/22/2022]
Abstract
A prospective and multi-centre study has allowed us to analyse antibody responses and Mycobacterium tuberculosis clinical isolate genotypes on 24 consecutive HIV-TB co-infected patients treated with Highly Active Antiretroviral Therapy (HAART) who either went on to develop a TB Immune Restoration Syndrome (TB-IRS), or not. Circulating free and immune-complexed antibodies against ManLAM, ESAT-6/CFP10 and PGL-Tb1 in HIV-TB co-infected patients were measured by ELISA at the initiation of anti-TB treatment, at the date of HAART initiation and thereafter. Presence of circulating B cells was also monitored by in vitro antibody production (IVAP) against ESAT-6/CFP10 and PGL-Tb1. Finally, 16 out of 24M. tuberculosis clinical isolates from patients with TB-IRS were genotyped using spoligotyping and MIRUs-VNTR typing. Eleven patients (45.8%) experienced TB-IRS (TB-IRS+). Significantly, lower anti-PGL-Tb1 antibody levels were identified in TB-IRS+ compared to TB-IRS-negative patients prior to TB-IRS development. These very low levels were neither related to CD4 counts nor with complexed antibodies. No difference in antibody levels was observed with the other tested antigens. In addition, no specific strain genotype was associated with TB-IRS. The presence of specific anti-PGL-Tb1 antibodies only in TB-IRS-negative patients represents for the first time an indicator of a potential protective response or a diagnostic biomarker for the detection of non-progression to TB-IRS in HIV-TB co-infected patients starting HAART.
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Affiliation(s)
- N Simonney
- EA3510, UFR Denis Diderot, Université Paris VII et Service de Microbiologie, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, CIB HOG, Paris, France
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Abstract
PURPOSE OF REVIEW The purpose of this review is to describe the epidemiology, clinical features, putative immune mechanisms and management of immune reconstitution inflammatory syndrome (IRIS) using data published in the last 2 years. RECENT FINDINGS Ever more conditions are reported as IRIS events. These most frequently occur with mycobacterial (tuberculosis or Mycobacterium avium complex infection) or cryptococcal disease (each in approximately 30% of cases). Definitions have been proposed for its clinical diagnosis. These suffer from a lack of prospective studies to support their predictive value. The immunopathogenesis of IRIS appears to be related to the interaction between HAART-induced changes in host immune response and the presence of (usually microbial) antigen. Increasing evidence exists that this might be an anatomically compartmentalized phenomenon, such that immune responses may be localized to specific tissue sites such as the brain. This has implications for the use of simple blood tests, such as CD4 count or change in viral load, when assessing risk of IRIS. Treatment options include immune modulation, though supportive care is typically all that is required, unless symptoms are prolonged, significant or life-threatening. SUMMARY IRIS is common and will become more so as HAART is rolled out worldwide. Clear clinical definitions are required to avoid its over-diagnosis due to misclassification of other conditions.
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Affiliation(s)
- Marc Lipman
- Department of HIV and Respiratory Medicine, Royal Free Hospital, London, UK.
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