1
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McNally E, Ross C, Gleeson LE. The tuberculous pleural effusion. Breathe (Sheff) 2023; 19:230143. [PMID: 38125799 PMCID: PMC10729824 DOI: 10.1183/20734735.0143-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 11/06/2023] [Indexed: 12/23/2023] Open
Abstract
Pleural tuberculosis (TB) is a common entity with similar epidemiological characteristics to pulmonary TB. It represents a spectrum of disease that can variably self-resolve or progress to TB empyema with severe sequelae such as chronic fibrothorax or empyema necessitans. Coexistence of and progression to pulmonary TB is high. Diagnosis is challenging, as pleural TB is paucibacillary in most cases, but every effort should be made to obtain microbiological diagnosis, especially where drug resistance is suspected. Much attention has been focussed on adjunctive investigations to support diagnosis, but clinicians must be aware that apparent diagnostic accuracy is affected both by the underlying TB prevalence in the population, and by the diagnostic standard against which the specified investigation is being evaluated. Pharmacological treatment of pleural TB is similar to that of pulmonary TB, but penetration of the pleural space may be suboptimal in complicated effusions. Evidence for routine drainage is limited, but evacuation of the pleural space is indicated in complicated disease. Educational aims To demonstrate that pleural TB incorporates a wide spectrum of disease, ranging from self-resolving lymphocytic effusions to severe TB empyema with serious sequelae.To emphasise the high coexistence of pulmonary TB with pleural TB, and the importance of obtaining sputum for culture (induced if necessary) in all cases.To explore the significant diagnostic challenges posed by pleural TB, and consequently the frequent lack of information about drug sensitivity prior to initiating treatment.To highlight the influence of underlying TB prevalence in the population on the diagnostic accuracy of adjunctive investigations for the diagnosis of pleural TB.To discuss concerns around penetration of anti-TB medications into the pleural space and how this can influence decisions around treatment duration in practice.
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Affiliation(s)
- Emma McNally
- Department of Respiratory Medicine, St James's Hospital, Dublin, Ireland
| | - Clare Ross
- Department of Respiratory Medicine, Imperial NHS Healthcare Trust, London, UK
| | - Laura E. Gleeson
- Department of Respiratory Medicine, St James's Hospital, Dublin, Ireland
- Department of Clinical Medicine, Trinity College Dublin School of Medicine, St James's Hospital, Dublin, Ireland
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2
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Unstimulated Pleural Fluid Interferon Gamma for Diagnosis of Tuberculous Pleural Effusion: a Systematic Review and Meta-analysis. J Clin Microbiol 2021; 59:JCM.02112-20. [PMID: 33208475 DOI: 10.1128/jcm.02112-20] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Unstimulated interferon gamma may be a useful pleural fluid biomarker in the diagnosis of tuberculous pleural effusion (TPE). However, the exact threshold of pleural fluid interferon gamma and its accuracy during routine clinical decision-making is not clear. We assessed the performance of pleural fluid interferon gamma in diagnosing TPE and tried to identify a useful assay threshold. We queried the PubMed and Embase databases for publications indexed until May 2020 that provided both sensitivity and specificity data on unstimulated pleural fluid interferon gamma for diagnosis of TPE. A bivariate random effects model was employed to compute summary estimates for diagnostic accuracy parameters, both overall as well as at threshold ranges of <2, 2 to 5, and >5 IU/ml. We retrieved 2,048 citations, of which 67 publications (7,153 patients) were assessed in our review. The summary estimates for sensitivity, specificity, and diagnostic odds ratio were 0.93 (95% confidence interval [CI], 0.91 to 0.95), 0.96 (95% CI, 0.94 to 0.97), and 310.72 (95% CI, 185.24 to 521.18), respectively. Increasing interferon gamma thresholds did not translate into any substantial change in diagnostic performance; however, eight studies using thresholds of >5 IU/ml showed poorer diagnostic accuracy estimates than other studies with lower thresholds. None of the prespecified subgroup variables significantly influenced relative diagnostic odds ratios in a multivariate meta-regression model. All publications demonstrated a high risk of bias. Unstimulated pleural fluid interferon gamma level provides excellent accuracy for diagnosing TPE and has the potential of becoming a first-line test for this purpose.
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3
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Tuberculous Meningitis: Pathogenesis, Immune Responses, Diagnostic Challenges, and the Potential of Biomarker-Based Approaches. J Clin Microbiol 2021; 59:JCM.01771-20. [PMID: 33087432 PMCID: PMC8106718 DOI: 10.1128/jcm.01771-20] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Tuberculous meningitis (TBM) is the most devastating form of tuberculosis (TB), causing high mortality or disability. Clinical management of the disease is challenging due to limitations of the existing diagnostic approaches. Our knowledge on the immunology and pathogenesis of the disease is currently limited. More research is urgently needed to enhance our understanding of the immunopathogenesis of the disease and guide us toward the identification of targets that may be useful for vaccines or host-directed therapeutics. Tuberculous meningitis (TBM) is the most devastating form of tuberculosis (TB), causing high mortality or disability. Clinical management of the disease is challenging due to limitations of the existing diagnostic approaches. Our knowledge on the immunology and pathogenesis of the disease is currently limited. More research is urgently needed to enhance our understanding of the immunopathogenesis of the disease and guide us toward the identification of targets that may be useful for vaccines or host-directed therapeutics. In this review, we summarize the current knowledge about the immunology and pathogenesis of TBM and summarize the literature on existing and new, especially biomarker-based, approaches that may be useful in the management of TBM. We identify research gaps and provide directions for research which may lead to the development of new tools for the control of the disease in the near future.
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4
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Cresswell FV, Davis AG, Sharma K, Basu Roy R, Ganiem AR, Kagimu E, Solomons R, Wilkinson RJ, Bahr NC, Thuong NTT. Recent Developments in Tuberculous Meningitis Pathogenesis and Diagnostics. Wellcome Open Res 2021; 4:164. [PMID: 33364436 PMCID: PMC7739117 DOI: 10.12688/wellcomeopenres.15506.3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2021] [Indexed: 12/13/2022] Open
Abstract
The pathogenesis of Tuberculous meningitis (TBM) is poorly understood, but contemporary molecular biology technologies have allowed for recent improvements in our understanding of TBM. For instance, neutrophils appear to play a significant role in the immunopathogenesis of TBM, and either a paucity or an excess of inflammation can be detrimental in TBM. Further, severity of HIV-associated immunosuppression is an important determinant of inflammatory response; patients with the advanced immunosuppression (CD4+ T-cell count of <150 cells/μL) having higher CSF neutrophils, greater CSF cytokine concentrations and higher mortality than those with CD4+ T-cell counts > 150 cells/μL. Host genetics may also influence outcomes with LT4AH genotype predicting inflammatory phenotype, steroid responsiveness and survival in Vietnamese adults with TBM. Whist in Indonesia, CSF tryptophan level was a predictor of survival, suggesting tryptophan metabolism may be important in TBM pathogenesis. These varying responses mean that we must consider whether a "one-size-fits-all" approach to anti-bacillary or immunomodulatory treatment in TBM is truly the best way forward. Of course, to allow for proper treatment, early and rapid diagnosis of TBM must occur. Diagnosis has always been a challenge but the field of TB diagnosis is evolving, with sensitivities of at least 70% now possible in less than two hours with GeneXpert MTB/Rif Ultra. In addition, advanced molecular techniques such as CRISPR-MTB and metagenomic next generation sequencing may hold promise for TBM diagnosis. Host-based biomarkers and signatures are being further evaluated in childhood and adult TBM as adjunctive biomarkers as even with improved molecular assays, cases are still missed. A better grasp of host and pathogen behaviour may lead to improved diagnostics, targeted immunotherapy, and possibly biomarker-based, patient-specific treatment regimens.
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Affiliation(s)
- Fiona V Cresswell
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Research Department, Infectious Diseases Institute, Kampala, PO Box 22418, Uganda
- MRC-UVRI-London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Angharad G. Davis
- University College London, London, WC1E6BT, UK
- Francis Crick Institute, London, NW1 1AT, UK
- Department of Medicine, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, 7925, South Africa
| | - Kusum Sharma
- Department of Medical Microbiology, Post-graduate Department of Medical Education and Research, Chandigahr, India
| | - Robindra Basu Roy
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Ahmad Rizal Ganiem
- Department of Neurology, Hasan Sadikin Hospital, Faculty of Medicine. Universitas Padjadjaran, Bandung, Indonesia
| | - Enock Kagimu
- Research Department, Infectious Diseases Institute, Kampala, PO Box 22418, Uganda
| | - Regan Solomons
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | - Robert J. Wilkinson
- Francis Crick Institute, London, NW1 1AT, UK
- Department of Medicine, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, 7925, South Africa
- Department of Infectious Diseases, Imperial College, London, W2 1PG, UK
| | - Nathan C Bahr
- Division of Infectious Diseases. Department of Medicine., University of Kansas, Kansas City, USA
| | | | - Tuberculous Meningitis International Research Consortium
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Research Department, Infectious Diseases Institute, Kampala, PO Box 22418, Uganda
- MRC-UVRI-London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- University College London, London, WC1E6BT, UK
- Francis Crick Institute, London, NW1 1AT, UK
- Department of Medicine, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, 7925, South Africa
- Department of Medical Microbiology, Post-graduate Department of Medical Education and Research, Chandigahr, India
- Department of Neurology, Hasan Sadikin Hospital, Faculty of Medicine. Universitas Padjadjaran, Bandung, Indonesia
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
- Department of Infectious Diseases, Imperial College, London, W2 1PG, UK
- Division of Infectious Diseases. Department of Medicine., University of Kansas, Kansas City, USA
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
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5
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Cresswell FV, Davis AG, Sharma K, Basu Roy R, Ganiem AR, Kagimu E, Solomons R, Wilkinson RJ, Bahr NC, Thuong NTT. Recent Developments in Tuberculous Meningitis Pathogenesis and Diagnostics. Wellcome Open Res 2020; 4:164. [PMID: 33364436 PMCID: PMC7739117 DOI: 10.12688/wellcomeopenres.15506.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2020] [Indexed: 12/15/2022] Open
Abstract
The pathogenesis of Tuberculous meningitis (TBM) is poorly understood, but contemporary molecular biology technologies have allowed for recent improvements in our understanding of TBM. For instance, neutrophils appear to play a significant role in the immunopathogenesis of TBM, and either a paucity or an excess of inflammation can be detrimental in TBM. Further, severity of HIV-associated immunosuppression is an important determinant of inflammatory response; patients with the advanced immunosuppression (CD4+ T-cell count of <150 cells/μL) having higher CSF neutrophils, greater CSF cytokine concentrations and higher mortality than those with CD4+ T-cell counts > 150 cells/μL. Host genetics may also influence outcomes with LT4AH genotype predicting inflammatory phenotype, steroid responsiveness and survival in Vietnamese adults with TBM. Whist in Indonesia, CSF tryptophan level was a predictor of survival, suggesting tryptophan metabolism may be important in TBM pathogenesis. These varying responses mean that we must consider whether a "one-size-fits-all" approach to anti-bacillary or immunomodulatory treatment in TBM is truly the best way forward. Of course, to allow for proper treatment, early and rapid diagnosis of TBM must occur. Diagnosis has always been a challenge but the field of TB diagnosis is evolving, with sensitivities of at least 70% now possible in less than two hours with GeneXpert MTB/Rif Ultra. In addition, advanced molecular techniques such as CRISPR-MTB and metagenomic next generation sequencing may hold promise for TBM diagnosis. Host-based biomarkers and signatures are being further evaluated in childhood and adult TBM as adjunctive biomarkers as even with improved molecular assays, cases are still missed. A better grasp of host and pathogen behaviour may lead to improved diagnostics, targeted immunotherapy, and possibly biomarker-based, patient-specific treatment regimens.
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Affiliation(s)
- Fiona V Cresswell
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Research Department, Infectious Diseases Institute, Kampala, PO Box 22418, Uganda
- MRC-UVRI-London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Angharad G. Davis
- University College London, London, WC1E6BT, UK
- Francis Crick Institute, London, NW1 1AT, UK
- Department of Medicine, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, 7925, South Africa
| | - Kusum Sharma
- Department of Medical Microbiology, Post-graduate Department of Medical Education and Research, Chandigahr, India
| | - Robindra Basu Roy
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Ahmad Rizal Ganiem
- Department of Neurology, Hasan Sadikin Hospital, Faculty of Medicine. Universitas Padjadjaran, Bandung, Indonesia
| | - Enock Kagimu
- Research Department, Infectious Diseases Institute, Kampala, PO Box 22418, Uganda
| | - Regan Solomons
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | - Robert J. Wilkinson
- Francis Crick Institute, London, NW1 1AT, UK
- Department of Medicine, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, 7925, South Africa
- Department of Infectious Diseases, Imperial College, London, W2 1PG, UK
| | - Nathan C Bahr
- Division of Infectious Diseases. Department of Medicine., University of Kansas, Kansas City, USA
| | | | - Tuberculous Meningitis International Research Consortium
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Research Department, Infectious Diseases Institute, Kampala, PO Box 22418, Uganda
- MRC-UVRI-London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- University College London, London, WC1E6BT, UK
- Francis Crick Institute, London, NW1 1AT, UK
- Department of Medicine, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, 7925, South Africa
- Department of Medical Microbiology, Post-graduate Department of Medical Education and Research, Chandigahr, India
- Department of Neurology, Hasan Sadikin Hospital, Faculty of Medicine. Universitas Padjadjaran, Bandung, Indonesia
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
- Department of Infectious Diseases, Imperial College, London, W2 1PG, UK
- Division of Infectious Diseases. Department of Medicine., University of Kansas, Kansas City, USA
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
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6
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Isaiah S, Loots DT, Solomons R, van der Kuip M, Tutu Van Furth AM, Mason S. Overview of Brain-to-Gut Axis Exposed to Chronic CNS Bacterial Infection(s) and a Predictive Urinary Metabolic Profile of a Brain Infected by Mycobacterium tuberculosis. Front Neurosci 2020; 14:296. [PMID: 32372900 PMCID: PMC7186443 DOI: 10.3389/fnins.2020.00296] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 03/16/2020] [Indexed: 12/12/2022] Open
Abstract
A new paradigm in neuroscience has recently emerged - the brain-gut axis (BGA). The contemporary focus in this paradigm has been gut → brain ("bottom-up"), in which the gut-microbiome, and its perturbations, affects one's psychological state-of-mind and behavior, and is pivotal in neurodegenerative disorders. The emerging brain → gut ("top-down") concept, the subject of this review, proposes that dysfunctional brain health can alter the gut-microbiome. Feedback of this alternative bidirectional highway subsequently aggravates the neurological pathology. This paradigm shift, however, focuses upon non-communicable neurological diseases (progressive neuroinflammation). What of infectious diseases, in which pathogenic bacteria penetrate the blood-brain barrier and interact with the brain, and what is this effect on the BGA in bacterial infection(s) that cause chronic neuroinflammation? Persistent immune activity in the CNS due to chronic neuroinflammation can lead to irreversible neurodegeneration and neuronal death. The properties of cerebrospinal fluid (CSF), such as immunological markers, are used to diagnose brain disorders. But what of metabolic markers for such purposes? If a BGA exists, then chronic CNS bacterial infection(s) should theoretically be reflected in the urine. The premise here is that chronic CNS bacterial infection(s) will affect the gut-microbiome and that perturbed metabolism in both the CNS and gut will release metabolites into the blood that are filtered (kidneys) and excreted in the urine. Here we assess the literature on the effects of chronic neuroinflammatory diseases on the gut-microbiome caused by bacterial infection(s) of the CNS, in the context of information attained via metabolomics-based studies of urine. Furthermore, we take a severe chronic neuroinflammatory infectious disease - tuberculous meningitis (TBM), caused by Mycobacterium tuberculosis, and examine three previously validated CSF immunological biomarkers - vascular endothelial growth factor, interferon-gamma and myeloperoxidase - in terms of the expected changes in normal brain metabolism. We then model the downstream metabolic effects expected, predicting pivotal altered metabolic pathways that would be reflected in the urinary profiles of TBM subjects. Our cascading metabolic model should be adjustable to account for other types of CNS bacterial infection(s) associated with chronic neuroinflammation, typically prevalent, and difficult to distinguish from TBM, in the resource-constrained settings of poor communities.
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Affiliation(s)
- Simon Isaiah
- Human Metabolomics, Faculty of Natural and Agricultural Sciences, North-West University, Potchefstroom, South Africa
| | - Du Toit Loots
- Human Metabolomics, Faculty of Natural and Agricultural Sciences, North-West University, Potchefstroom, South Africa
| | - Regan Solomons
- Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Martijn van der Kuip
- Pediatric Infectious Diseases and Immunology, Amsterdam University Medical Center, Academic Medical Center, Emma Children’s Hospital, Amsterdam, Netherlands
| | - A. Marceline Tutu Van Furth
- Pediatric Infectious Diseases and Immunology, Amsterdam University Medical Center, Academic Medical Center, Emma Children’s Hospital, Amsterdam, Netherlands
| | - Shayne Mason
- Human Metabolomics, Faculty of Natural and Agricultural Sciences, North-West University, Potchefstroom, South Africa
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7
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Cresswell FV, Davis AG, Sharma K, Basu Roy R, Ganiem AR, Kagimu E, Solomons R, Wilkinson RJ, Bahr NC, Thuong NTT. Recent Developments in Tuberculous Meningitis Pathogenesis and Diagnostics. Wellcome Open Res 2019; 4:164. [PMID: 33364436 PMCID: PMC7739117 DOI: 10.12688/wellcomeopenres.15506.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2019] [Indexed: 12/15/2022] Open
Abstract
The pathogenesis of Tuberculous meningitis (TBM) is poorly understood, but contemporary molecular biology technologies have allowed for recent improvements in our understanding of TBM. For instance, neutrophils appear to play a significant role in the immunopathogenesis of TBM, and either a paucity or an excess of inflammation can be detrimental in TBM. Further, severity of HIV-associated immunosuppression is an important determinant of inflammatory response; patients with the advanced immunosuppression (CD4+ T-cell count of <150 cells/μL) having higher CSF neutrophils, greater CSF cytokine concentrations and higher mortality than those with CD4+ T-cell counts > 150 cells/μL. Host genetics may also influence outcomes with LT4AH genotype predicting inflammatory phenotype, steroid responsiveness and survival in Vietnamese adults with TBM. Whist in Indonesia, CSF tryptophan level was a predictor of survival, suggesting tryptophan metabolism may be important in TBM pathogenesis. These varying responses mean that we must consider whether a "one-size-fits-all" approach to anti-bacillary or immunomodulatory treatment in TBM is truly the best way forward. Of course, to allow for proper treatment, early and rapid diagnosis of TBM must occur. Diagnosis has always been a challenge but the field of TB diagnosis is evolving, with sensitivities of at least 70% now possible in less than two hours with GeneXpert MTB/Rif Ultra. In addition, advanced molecular techniques such as CRISPR-MTB and metagenomic next generation sequencing may hold promise for TBM diagnosis. Host-based biomarkers and signatures are being further evaluated in childhood and adult TBM as adjunctive biomarkers as even with improved molecular assays, cases are still missed. A better grasp of host and pathogen behaviour may lead to improved diagnostics, targeted immunotherapy, and possibly biomarker-based, patient-specific treatment regimens.
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Affiliation(s)
- Fiona V Cresswell
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Research Department, Infectious Diseases Institute, Kampala, PO Box 22418, Uganda
- MRC-UVRI-London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Angharad G. Davis
- University College London, London, WC1E6BT, UK
- Francis Crick Institute, London, NW1 1AT, UK
- Department of Medicine, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, 7925, South Africa
| | - Kusum Sharma
- Department of Medical Microbiology, Post-graduate Department of Medical Education and Research, Chandigahr, India
| | - Robindra Basu Roy
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Ahmad Rizal Ganiem
- Department of Neurology, Hasan Sadikin Hospital, Faculty of Medicine. Universitas Padjadjaran, Bandung, Indonesia
| | - Enock Kagimu
- Research Department, Infectious Diseases Institute, Kampala, PO Box 22418, Uganda
| | - Regan Solomons
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | - Robert J. Wilkinson
- Francis Crick Institute, London, NW1 1AT, UK
- Department of Medicine, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, 7925, South Africa
- Department of Infectious Diseases, Imperial College, London, W2 1PG, UK
| | - Nathan C Bahr
- Division of Infectious Diseases. Department of Medicine., University of Kansas, Kansas City, USA
| | | | - Tuberculous Meningitis International Research Consortium
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Research Department, Infectious Diseases Institute, Kampala, PO Box 22418, Uganda
- MRC-UVRI-London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- University College London, London, WC1E6BT, UK
- Francis Crick Institute, London, NW1 1AT, UK
- Department of Medicine, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, 7925, South Africa
- Department of Medical Microbiology, Post-graduate Department of Medical Education and Research, Chandigahr, India
- Department of Neurology, Hasan Sadikin Hospital, Faculty of Medicine. Universitas Padjadjaran, Bandung, Indonesia
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
- Department of Infectious Diseases, Imperial College, London, W2 1PG, UK
- Division of Infectious Diseases. Department of Medicine., University of Kansas, Kansas City, USA
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
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8
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Min F, Wang J, Huang S, Pan J, Zhang L. In vitro responses of multiple cytokines to purified protein derivative in healthy and naturally Mycobacterium tuberculosis-infected rhesus monkeys (Macaca mulatta). J Med Primatol 2019; 48:329-337. [PMID: 31478213 DOI: 10.1111/jmp.12433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 06/25/2019] [Accepted: 06/30/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND As the widely used biomarker of whole-blood stimulation assays for tuberculosis diagnosis, the release of IFN-γ might be affected by multiple factors, such as immunosuppression and some infectious agents. Here, we evaluated additional cytokines as diagnostic biomarkers. METHODS Forty-three cytokines were measured by Luminex xMAP technologies in 30 healthy and 10 naturally Mycobacterium tuberculosis (MTB)-infected rhesus monkeys pre- and post-stimulation by purified protein derivative (PPD). RESULTS After stimulation, production of 23 and 38 cytokines was markedly increased in healthy and MTB-infected macaques, respectively. A comparison of the stimulation index (SI) between MTB infections and healthy macaques showed that the SIs of 32 cytokines in MTB-infected macaques were significantly higher than those in healthy macaques. Pooling the results, eight cytokines were suggested as ideal biomarkers for a whole-blood stimulation assay for MTB diagnosis. CONCLUSION PPD could induce multiple cytokine responses in either healthy or MTB-infected monkeys, and eight cytokines had reliable predictive capacity as diagnostic biomarkers of MTB infection.
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Affiliation(s)
- Fangui Min
- Guangdong Laboratory Animals Monitoring Institute, Guangdong Provincial Key Laboratory of Laboratory Animals, Guangzhou, China
| | - Jing Wang
- Guangdong Laboratory Animals Monitoring Institute, Guangdong Provincial Key Laboratory of Laboratory Animals, Guangzhou, China
| | - Shuwu Huang
- Guangdong Laboratory Animals Monitoring Institute, Guangdong Provincial Key Laboratory of Laboratory Animals, Guangzhou, China
| | - Jinchun Pan
- Guangdong Laboratory Animals Monitoring Institute, Guangdong Provincial Key Laboratory of Laboratory Animals, Guangzhou, China
| | - Lan Zhang
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Obstetrics and Gynecology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
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9
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Shaw JA, Diacon AH, Koegelenberg CFN. Tuberculous pleural effusion. Respirology 2019; 24:962-971. [PMID: 31418985 DOI: 10.1111/resp.13673] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/05/2019] [Accepted: 07/23/2019] [Indexed: 12/19/2022]
Abstract
Tuberculous effusion is a common disease entity with a spectrum of presentations from a largely benign effusion, which resolves completely, to a complicated effusion with loculations, pleural thickening and even frank empyema, all of which may have a lasting effect on lung function. The pathogenesis is a combination of true pleural infection and an effusive hypersensitivity reaction, compartmentalized within the pleural space. Diagnostic thoracentesis with thorough pleural fluid analysis including biomarkers such as adenosine deaminase and gamma interferon achieves high accuracy in the correct clinical context. Definitive diagnosis may require invasive procedures to demonstrate histological evidence of caseating granulomas or microbiological evidence of the organism on smear or culture. Drug resistance is an emerging problem that requires vigilance and extra effort to acquire a complete drug sensitivity profile for each tuberculous effusion treated. Nucleic acid amplification tests such as Xpert MTB/RIF can be invaluable in this instance; however, the yield is low in pleural fluid. Treatment consists of standard anti-tuberculous therapy or a guideline-based individualized regimen in the case of drug resistance. There is low-quality evidence that suggests possible benefit from corticosteroids; however, they are not currently recommended due to concomitant increased risk of adverse effects. Small studies report some short- and long-term benefit from interventions such as therapeutic thoracentesis, intrapleural fibrinolytics and surgery but many questions remain to be answered.
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Affiliation(s)
- Jane A Shaw
- Division of Pulmonology, Department of Medicine, Tygerberg Academic Hospital and Stellenbosch University, Cape Town, South Africa
| | - Andreas H Diacon
- Division of Pulmonology, Department of Medicine, Tygerberg Academic Hospital and Stellenbosch University, Cape Town, South Africa
| | - Coenraad F N Koegelenberg
- Division of Pulmonology, Department of Medicine, Tygerberg Academic Hospital and Stellenbosch University, Cape Town, South Africa
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10
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Manngo PM, Gutschmidt A, Snyders CI, Mutavhatsindi H, Manyelo CM, Makhoba NS, Ahlers P, Hiemstra A, Stanley K, McAnda S, Kidd M, Malherbe ST, Walzl G, Chegou NN. Prospective evaluation of host biomarkers other than interferon gamma in QuantiFERON Plus supernatants as candidates for the diagnosis of tuberculosis in symptomatic individuals. J Infect 2019; 79:228-235. [PMID: 31319143 DOI: 10.1016/j.jinf.2019.07.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 07/02/2019] [Accepted: 07/12/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND There is an urgent need for new tools for the diagnosis of TB. We evaluated the usefulness recently described host biomarkers in supernatants from the newest generation of the QuantiFERON test (QuantiFERON Plus) as tools for the diagnosis of active TB. METHODS We recruited individuals presenting at primary health care clinics in Cape Town, South Africa with symptoms requiring investigation for TB disease, prior to the establishment of a clinical diagnosis. Participants were later classified as TB or other respiratory diseases (ORD) based on the results of clinical and laboratory tests. Using a multiplex platform, we evaluated the concentrations of 37 host biomarkers in QuantiFERON Plus supernatants from study participants as tools for the diagnosis of TB. RESULTS Out of 120 study participants, 35(29.2%) were diagnosed with active TB, 69(57.5%) with ORD whereas 16(13.3%) were excluded. 14(11.6%) of the study participants were HIV infected. Although individual host markers showed potential as diagnostic candidates, the main finding of the study was the identification of a six-marker biosignature in unstimulated supernatants (Apo-ACIII, CXCL1, CXCL9, CCL8, CCL-1, CD56) which diagnosed TB with sensitivity and specificity of 73.9%(95% CI; 51.6-87.8) and 87.6%(95% CI; 77.2-94.5), respectively, after leave-one-out cross validation. Combinations between TB-antigen specific biomarkers also showed potential (sensitivity of 77.3% and specificity of 69.2%, respectively), with multiple biomarkers being significantly different between TB patients, Quantiferon Plus Positive and Quantiferon Plus negative individuals with ORD, regardless of HIV status. CONCLUSIONS Biomarkers detected in QuantiFERON Plus supernatants may contribute to adjunctive diagnosis of TB.
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Affiliation(s)
- Portia M Manngo
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Po Box 241, Cape Town 8000, South Africa
| | - Andrea Gutschmidt
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Po Box 241, Cape Town 8000, South Africa
| | - Candice I Snyders
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Po Box 241, Cape Town 8000, South Africa
| | - Hygon Mutavhatsindi
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Po Box 241, Cape Town 8000, South Africa
| | - Charles M Manyelo
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Po Box 241, Cape Town 8000, South Africa
| | - Nonjabulo S Makhoba
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Po Box 241, Cape Town 8000, South Africa
| | - Petri Ahlers
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Po Box 241, Cape Town 8000, South Africa
| | - Andriette Hiemstra
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Po Box 241, Cape Town 8000, South Africa
| | - Kim Stanley
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Po Box 241, Cape Town 8000, South Africa
| | - Shirley McAnda
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Po Box 241, Cape Town 8000, South Africa
| | - Martin Kidd
- Centre for Statistical Consultation, Department of Statistics and Actuarial Sciences, Stellenbosch University, Cape Town, South Africa
| | - Stephanus T Malherbe
- Centre for Statistical Consultation, Department of Statistics and Actuarial Sciences, Stellenbosch University, Cape Town, South Africa
| | - Gerhard Walzl
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Po Box 241, Cape Town 8000, South Africa
| | - Novel N Chegou
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Po Box 241, Cape Town 8000, South Africa.
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11
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Application of Cerebrospinal Fluid Host Protein Biosignatures in the Diagnosis of Tuberculous Meningitis in Children from a High Burden Setting. Mediators Inflamm 2019; 2019:7582948. [PMID: 31148946 PMCID: PMC6501148 DOI: 10.1155/2019/7582948] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 01/14/2019] [Indexed: 02/07/2023] Open
Abstract
Background The diagnosis of tuberculous meningitis (TBM) especially in children is challenging. New tests are urgently needed for the diagnosis of the disease, especially in resource-limited settings. Methods We collected cerebrospinal fluid (CSF) samples from children presenting with symptoms requiring investigation for meningitis at a tertiary hospital in Cape Town, South Africa. Children were later classified as TBM or no TBM using published case definitions. Using a multiplex platform, we investigated the concentrations of biomarkers comprising a previously established 3-marker biosignature (VEGF, IL-13, and LL-37) and other potentially useful host biomarkers as diagnostic candidates for TBM. Findings Out of 47 children, age, 3 months to 13 years, 23 were diagnosed with TBM and six (16%) were HIV-infected. We validated the previously identified CSF biosignature (sensitivity of 95.7% (95% CI, 79.0-99.2%) and specificity of 37.5% (95% CI, 21.2-57.3%)). However, substitution of IL-13 and LL-37 with IFN-γ and MPO, respectively, resulted in improved accuracy (area under the ROC curve (AUC) = 0.97, 95% CI, 0.92-1.00, up to 91.3% (21/23) sensitivity and up to 100% (24/24) specificity). An alternative four-marker biosignature (sICAM-1, MPO, CXCL8, and IFN-γ) also showed potential, with an AUC of 0.97. Conclusion We validated a previously identified CSF biosignature and showed that refinement of this biosignature by incorporation of other biomarkers diagnosed TBM with high accuracy. Incorporation of these biomarkers into a point-of-care or bedside diagnostic test platform may result in the improved management of TBM in children.
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12
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Manyelo CM, Solomons RS, Snyders CI, Mutavhatsindi H, Manngo PM, Stanley K, Walzl G, Chegou NN. Potential of Host Serum Protein Biomarkers in the Diagnosis of Tuberculous Meningitis in Children. Front Pediatr 2019; 7:376. [PMID: 31612118 PMCID: PMC6773834 DOI: 10.3389/fped.2019.00376] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 09/02/2019] [Indexed: 01/22/2023] Open
Abstract
Background: Tuberculous meningitis (TBM) is the most severe form of tuberculosis and results in high morbidity and mortality in children. Diagnostic delay contributes to the poor outcome. There is an urgent need for new tools for the rapid diagnosis of TBM, especially in children. Methods: We collected serum samples from children in whom TBM was suspected at a tertiary hospital in Cape Town, South Africa. Children were subsequently classified as having TBM or no TBM using a published uniform research case-definition. Using a multiplex cytokine array platform, we investigated the concentrations of serum biomarkers comprising biomarkers that were previously found to be of value in the diagnosis of adult pulmonary TB (CRP, SAA, CFH, IFN-γ, IP-10, Apo-AI, and transthyretin) plus other potentially useful host biomarkers as diagnostic candidates for TBM. Findings: Out of 47 children included in the study, 23 (48.9%) had a final diagnosis of TBM and six were HIV infected. A modified version of the adult 7-marker biosignature in which transthyretin was replaced by NCAM1, diagnosed TBM in children with AUC of 0.80 (95% CI, 0.67-0.92), sensitivity of 73.9% (95% CI, 51.6-89.8%) and specificity of 66.7% (95% CI, 44.7-84.4%), with the other six proteins in the signature (CRP, IFN-γ, IP-10, CFH, Apo-A1, and SAA) only achieving and AUC of 0.75 (95% CI, 0.61-0.90) when used in combination. A new childhood TBM specific 3-marker biosignature (adipsin, Aβ42, and IL-10) showed potential in the diagnosis of TBM, with AUC of 0.84 (95% CI, 0.73-0.96), sensitivity of 82.6% (95 CI, 61.2-95.0%) and specificity of 75.0% (95% CI, 53.3-90.2%) after leave-one-out cross validation. Conclusion: A previously described adult 7-marker serum protein biosignature showed potential in the diagnosis of TBM in children. However, a smaller childhood TBM-specific 3-marker signature demonstrated improved performance characteristics. Our data indicates that blood-based biomarkers may be useful in the diagnosis of childhood TBM and requires further validation in larger cohort studies.
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Affiliation(s)
- Charles M Manyelo
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Regan S Solomons
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Candice I Snyders
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Hygon Mutavhatsindi
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Portia M Manngo
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Kim Stanley
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Gerhard Walzl
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Novel N Chegou
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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13
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Shaw JA, Irusen EM, Diacon AH, Koegelenberg CF. Pleural tuberculosis: A concise clinical review. CLINICAL RESPIRATORY JOURNAL 2018; 12:1779-1786. [PMID: 29660258 DOI: 10.1111/crj.12900] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/23/2018] [Accepted: 04/04/2018] [Indexed: 12/18/2022]
Abstract
Tuberculosis (TB) is the leading infectious cause of death worldwide, and the commonest cause of death in people living with HIV. Globally, pleural TB remains one of the most frequent causes of pleural exudates, particularly in TB-endemic areas and in the HIV positive population. Most TB pleural effusions are exudates with high adenosine deaminase (ADA), lymphocyte-rich, straw-coloured and free flowing, with a low yield on mycobacterial culture. TB pleurisy can also present as loculated neutrophil-predominant effusions which mimic parapneumonic effusions. Rarely, they can present as frank TB empyema, containing an abundance of mycobacteria. Up to 80% of patients have parenchymal involvement on chest imaging. The diagnosis is simple if M. tuberculosis is detected in sputum, pleural fluid or biopsy specimens, and the recent advent of liquid medium culture techniques has increased the microbiological yield dramatically. Where the prevalence of TB is high the presence of a lymphocyte-predominant exudate with a high ADA has a positive predictive value of 98%. In low prevalence areas, the absence of an elevated ADA and lymphocyte predominance makes TB very unlikely, and pleural biopsy should be performed to confirm the diagnosis. Pleural biopsy for liquid culture and susceptibility testing must also be considered where the prevalence of drug resistant TB is high. Treatment regimens are identical to those administered for pulmonary TB. Initial pleural drainage may have a role in symptom relief and in hastening the resolution of the effusion. Surgical intervention may be required in loculated effusions and empyemas.
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Affiliation(s)
- Jane A Shaw
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Elvis M Irusen
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Andreas H Diacon
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Coenraad F Koegelenberg
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
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14
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Chegou NN, Sutherland JS, Namuganga AR, Corstjens PL, Geluk A, Gebremichael G, Mendy J, Malherbe S, Stanley K, van der Spuy GD, Kriel M, Loxton AG, Kriel B, Simukonda F, Bekele Y, Sheehama JA, Nelongo J, van der Vyver M, Gebrexabher A, Hailu H, Esterhuyse MM, Rosenkrands I, Aagard C, Kidd M, Kassa D, Mihret A, Howe R, Cliff JM, Crampin AC, Mayanja-Kizza H, Kaufmann SHE, Dockrell HM, Ottenhoff THM, Walzl G. Africa-wide evaluation of host biomarkers in QuantiFERON supernatants for the diagnosis of pulmonary tuberculosis. Sci Rep 2018; 8:2675. [PMID: 29422548 PMCID: PMC5805775 DOI: 10.1038/s41598-018-20855-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 01/25/2018] [Indexed: 11/30/2022] Open
Abstract
We investigated host-derived biomarkers that were previously identified in QuantiFERON supernatants, in a large pan-African study. We recruited individuals presenting with symptoms of pulmonary TB at seven peripheral healthcare facilities in six African countries, prior to assessment for TB disease. We then evaluated the concentrations of 12 biomarkers in stored QuantiFERON supernatants using the Luminex platform. Based on laboratory, clinical and radiological findings and a pre-established algorithm, participants were classified as TB disease or other respiratory diseases(ORD). Of the 514 individuals included in the study, 179(34.8%) had TB disease, 274(51.5%) had ORD and 61(11.5%) had an uncertain diagnosis. A biosignature comprising unstimulated IFN-γ, MIP-1β, TGF-α and antigen-specific levels of TGF-α and VEGF, identified on a training sample set (n = 311), validated by diagnosing TB disease in the test set (n = 134) with an AUC of 0.81(95% CI, 0.76–0.86), corresponding to a sensitivity of 64.2%(95% CI, 49.7–76.5%) and specificity of 82.7%(95% CI, 72.4–89.9%). Host biomarkers detected in QuantiFERON supernatants can contribute to the diagnosis of active TB disease amongst people presenting with symptoms requiring investigation for TB disease, regardless of HIV status or ethnicity in Africa.
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Affiliation(s)
- Novel N Chegou
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa.
| | - Jayne S Sutherland
- Vaccines and Immunity, Medical Research Council Unit, Fajara, The Gambia
| | - Anna-Ritah Namuganga
- Uganda-Case Western Research Collaboration - Makerere University, PO Box 663, Kampala, Uganda
| | - Paul Lam Corstjens
- Department of Molecular Cell Biology, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Annemieke Geluk
- Department of Infectious Diseases, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | | | - Joseph Mendy
- Vaccines and Immunity, Medical Research Council Unit, Fajara, The Gambia
| | - Stephanus Malherbe
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
| | - Kim Stanley
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
| | - Gian D van der Spuy
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
| | - Magdalena Kriel
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
| | - Andre G Loxton
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
| | - Belinda Kriel
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
| | - Felanji Simukonda
- Karonga Prevention Study, Chilumba, Malawi.,URC Malawi Lab Project, PO Box 1921, Lilongwe, Malawi
| | - Yonas Bekele
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Jacob A Sheehama
- School of Medicine, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Josefina Nelongo
- School of Medicine, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Marieta van der Vyver
- School of Medicine, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | | | - Habteyes Hailu
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Maria M Esterhuyse
- Department of Immunology, Max Planck Institute for Infection Biology, Charitéplatz 1, 10117, Berlin, Germany
| | - Ida Rosenkrands
- Department of Infectious Disease Immunology, Statens Serum Institut, Copenhagen, 2300s, Denmark
| | - Claus Aagard
- Department of Infectious Disease Immunology, Statens Serum Institut, Copenhagen, 2300s, Denmark
| | - Martin Kidd
- Centre for Statistical Consultation, Department of Statistics and Actuarial Sciences, Stellenbosch University, Cape Town, South Africa
| | - Desta Kassa
- Department of Infectious Diseases, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Adane Mihret
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Rawleigh Howe
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Jacqueline M Cliff
- Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | | | | | - Stefan H E Kaufmann
- Department of Immunology, Max Planck Institute for Infection Biology, Charitéplatz 1, 10117, Berlin, Germany
| | - Hazel M Dockrell
- Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Tom H M Ottenhoff
- Department of Infectious Diseases, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Gerhard Walzl
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa.
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15
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Liu Y, Ou Q, Zheng J, Shen L, Zhang B, Weng X, Shao L, Gao Y, Zhang W. A combination of the QuantiFERON-TB Gold In-Tube assay and the detection of adenosine deaminase improves the diagnosis of tuberculous pleural effusion. Emerg Microbes Infect 2016; 5:e83. [PMID: 27485497 PMCID: PMC5034099 DOI: 10.1038/emi.2016.80] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 05/12/2016] [Accepted: 05/18/2016] [Indexed: 01/24/2023]
Abstract
The differential diagnosis of tuberculous pleural effusion (TPE) and malignant pleural effusion (MPE) remains difficult despite the availability of numerous diagnostic tools. The current study aimed to evaluate the performance of the whole blood QuantiFERON-TB Gold In-Tube (QFT-GIT) assay and conventional laboratory biomarkers in differential diagnosis of TPE and MPE in high tuberculosis prevalence areas. A total of 117 patients with pleural effusions were recruited, including 91 with TPE and 26 with MPE. All of the patients were tested with QFT-GIT, and the conventional biomarkers in both blood and pleural effusion were detected. The level of antigen-stimulated QFT-GIT in the whole blood of TPE patients was significantly higher than that of MPE (2.89 vs 0.33 IU/mL, P<0.0001). The sensitivity and specificity of QFT-GIT for the diagnosis of TPE were 93.0% and 60.0%, respectively. Among the biomarkers in blood and pleural effusion, pleural adenosine deaminase (ADA) was the most prominent biomarker, with a cutoff value of 15.35 IU/L. The sensitivity and specificity for the diagnosis of TPE were 93.4% and 96.2%, respectively. The diagnostic classification tree from the combination of these two biomarkers was 97.8% sensitive and 92.3% specific. Ultimately, the combination of whole blood QFT-GIT with pleural ADA improved both the specificity and positive predictive value to 100%. Thus, QFT-GIT is not superior to pleural ADA in the differential diagnosis of TPE and MPE. Combined whole blood QFT-GIT and pleural ADA detection can improve the diagnosis of TPE.
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Affiliation(s)
- Yuanyuan Liu
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Qinfang Ou
- Department of Pulmonary Diseases, Wuxi No. 5 People's Hospital, Wuxi 214005, Jiangsu Province, China
| | - Jian Zheng
- Department of Pulmonary Diseases, Wuxi No. 5 People's Hospital, Wuxi 214005, Jiangsu Province, China
| | - Lei Shen
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Bingyan Zhang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Xinhua Weng
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Lingyun Shao
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yan Gao
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Wenhong Zhang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai 200040, China.,Key Laboratory of Medical Molecular Virology, Ministry of Education and Health, Shanghai Medical College, Fudan University, Shanghai 200032, China
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16
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Jacobs R, Maasdorp E, Malherbe S, Loxton AG, Stanley K, van der Spuy G, Walzl G, Chegou NN. Diagnostic Potential of Novel Salivary Host Biomarkers as Candidates for the Immunological Diagnosis of Tuberculosis Disease and Monitoring of Tuberculosis Treatment Response. PLoS One 2016; 11:e0160546. [PMID: 27487181 PMCID: PMC4972428 DOI: 10.1371/journal.pone.0160546] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 07/21/2016] [Indexed: 01/05/2023] Open
Abstract
Background There is an urgent need for new tools for the early diagnosis of TB disease and monitoring of the response to treatment, especially in resource-constrained settings. We investigated the usefulness of host markers detected in saliva as candidate biomarkers for the immunological diagnosis of TB disease and monitoring of treatment response. Methods We prospectively collected saliva samples from 51 individuals that presented with signs and symptoms suggestive of TB disease at a health centre in Cape Town, South Africa, prior to the establishment of a clinical diagnosis. Patients were later classified as having TB disease or other respiratory disease (ORD), using a combination of clinical, radiological and laboratory findings. We evaluated the concentrations of 69 host markers in saliva samples using a multiplex cytokine platform, and assessed the diagnostic potentials of these markers by receiver operator characteristics (ROC) curve analysis, and general discriminant analysis. Results Out of the 51 study participants, 18 (35.4%) were diagnosed with TB disease and 12 (23.5%) were HIV infected. Only two of the 69 host markers that were evaluated (IL-16 and IL-23) diagnosed TB disease individually with area under the ROC curve ≥0.70. A five-marker biosignature comprising of IL-1β, IL-23, ECM-1, HCC1 and fibrinogen diagnosed TB disease with a sensitivity of 88.9% (95% CI,76.7–99.9%) and specificity of 89.7% (95% CI, 60.4–96.6%) after leave-one-out cross validation, regardless of HIV infection status. Eight-marker biosignatures performed with a sensitivity of 100% (95% CI, 83.2–100%) and specificity of 95% (95% CI, 68.1–99.9%) in the absence of HIV infection. Furthermore, the concentrations of 11 of the markers changed during treatment, indicating that they may be useful in monitoring of TB treatment response. Conclusion We have identified novel salivary biosignatures which may be useful in the diagnosis of TB disease and monitoring of the response to TB treatment. Our findings require further validation in larger studies before these biosignatures could be considered for point-of-care screening test development.
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Affiliation(s)
- Ruschca Jacobs
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Elizna Maasdorp
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Stephanus Malherbe
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Andre G. Loxton
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Kim Stanley
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Gian van der Spuy
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Gerhard Walzl
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Novel N. Chegou
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- * E-mail:
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Chegou NN, Sutherland JS, Malherbe S, Crampin AC, Corstjens PLAM, Geluk A, Mayanja-Kizza H, Loxton AG, van der Spuy G, Stanley K, Kotzé LA, van der Vyver M, Rosenkrands I, Kidd M, van Helden PD, Dockrell HM, Ottenhoff THM, Kaufmann SHE, Walzl G. Diagnostic performance of a seven-marker serum protein biosignature for the diagnosis of active TB disease in African primary healthcare clinic attendees with signs and symptoms suggestive of TB. Thorax 2016; 71:785-94. [PMID: 27146200 DOI: 10.1136/thoraxjnl-2015-207999] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 04/11/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND User-friendly, rapid, inexpensive yet accurate TB diagnostic tools are urgently needed at points of care in resource-limited settings. We investigated host biomarkers detected in serum samples obtained from adults with signs and symptoms suggestive of TB at primary healthcare clinics in five African countries (Malawi, Namibia, South Africa, The Gambia and Uganda), for the diagnosis of TB disease. METHODS We prospectively enrolled individuals presenting with symptoms warranting investigation for pulmonary TB, prior to assessment for TB disease. We evaluated 22 host protein biomarkers in stored serum samples using a multiplex cytokine platform. Using a pre-established diagnostic algorithm comprising of laboratory, clinical and radiological findings, participants were classified as either definite TB, probable TB, questionable TB status or non-pulmonary TB. RESULTS Of the 716 participants enrolled, 185 were definite and 29 were probable TB cases, 6 had questionable TB disease status, whereas 487 had no evidence of TB. A seven-marker biosignature of C reactive protein, transthyretin, IFN-γ, complement factor H, apolipoprotein-A1, inducible protein 10 and serum amyloid A identified on a training sample set (n=491), diagnosed TB disease in the test set (n=210) with sensitivity of 93.8% (95% CI 84.0% to 98.0%), specificity of 73.3% (95% CI 65.2% to 80.1%), and positive and negative predictive values of 60.6% (95% CI 50.3% to 70.1%) and 96.4% (95% CI 90.5% to 98.8%), respectively, regardless of HIV infection status or study site. CONCLUSIONS We have identified a seven-marker host serum protein biosignature for the diagnosis of TB disease irrespective of HIV infection status or ethnicity in Africa. These results hold promise for the development of a field-friendly point-of-care screening test for pulmonary TB.
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Affiliation(s)
- Novel N Chegou
- Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, DST/NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa
| | - Jayne S Sutherland
- Vaccines and Immunity, Medical Research Council Unit, Fajara, The Gambia
| | - Stephanus Malherbe
- Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, DST/NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa
| | | | - Paul L A M Corstjens
- Department of Molecular Cell Biology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Annemieke Geluk
- Department of Infectious Diseases, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Andre G Loxton
- Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, DST/NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa
| | - Gian van der Spuy
- Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, DST/NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa
| | - Kim Stanley
- Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, DST/NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa
| | - Leigh A Kotzé
- Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, DST/NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa
| | - Marieta van der Vyver
- Faculty of Health Sciences, School of Medicine, University of Namibia, Windhoek, Namibia
| | - Ida Rosenkrands
- Department of Infectious Disease Immunology, Statens Serum Institut, Copenhagen, Denmark
| | - Martin Kidd
- Department of Statistics and Actuarial Sciences, Centre for Statistical Consultation, Stellenbosch University, Cape Town, South Africa
| | - Paul D van Helden
- Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, DST/NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa
| | - Hazel M Dockrell
- Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, UK
| | - Tom H M Ottenhoff
- Department of Infectious Diseases, Leiden University Medical Centre, Leiden, The Netherlands
| | - Stefan H E Kaufmann
- Department of Immunology, Max Planck Institute for Infection Biology, Berlin, Germany
| | - Gerhard Walzl
- Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, DST/NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa
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Santin M, García-García JM, Domínguez J. Guidelines for the use of interferon-γ release assays in the diagnosis of tuberculosis infection. Enferm Infecc Microbiol Clin 2016; 34:303.e1-13. [PMID: 26917222 DOI: 10.1016/j.eimc.2015.11.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 11/16/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Interferon-gamma release assays are widely used for the diagnosis of tuberculosis infection in low-prevalence countries. However, there is no consensus on their application. The objective of this study was to develop guidelines for the use of interferon-gamma release assays in specific clinical scenarios in Spain. METHODS A panel of experts comprising specialists in infectious diseases, respiratory diseases, microbiology, pediatrics and preventive medicine, together with a methodologist, formulated the clinical questions and outcomes of interest. They conducted a systematic literature search, summarized the evidence and rated its quality, and prepared the recommendations following the GRADE (Grading of Recommendations of Assessment Development and Evaluations) methodology. RESULTS The panel prepared recommendations on the use of interferon-gamma release assays for the diagnosis of tuberculosis infection in the contact-tracing study (both adults and children), health care workers, immunosuppressed patients (patients infected with human immunodeficiency virus, patients with chronic immunomediated inflammatory diseases due to start biological therapy and patients requiring organ transplant) and for the diagnosis of active tuberculosis. Most recommendations were weak, mainly due to the lack of good quality evidence to balance the clinical benefits and disadvantages of the interferon-gamma release assays as compared with the tuberculin skin test. CONCLUSION This document provides evidence-based guidance on the use of interferon-gamma release assays for the diagnosis of tuberculosis infection in patients at risk of tuberculosis or with suspicion of active disease. The guidelines will be applicable in specialist and primary care and in public health settings.
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Affiliation(s)
- Miguel Santin
- Service of Infectious Diseases, Bellvitge University Hospital-IDIBELL, Barcelona, Spain; Department of Clinical Sciences, University of Barcelona, Barcelona, Spain
| | | | - José Domínguez
- Service of Microbiology, Research Institute Trias i Pujol, Hospital Gremans Trias i Pujol, Barcelona, Spain; Department of Genetics and Microbiology, Universidad Autónoma de Barcelona, Barcelona, Spain; CIBER Respiratory Diseases, Madrid, Spain.
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Zhou XX, Liu YL, Zhai K, Shi HZ, Tong ZH. Body Fluid Interferon-γ Release Assay for Diagnosis of Extrapulmonary Tuberculosis in Adults: A Systematic Review and Meta-Analysis. Sci Rep 2015; 5:15284. [PMID: 26503802 PMCID: PMC4621514 DOI: 10.1038/srep15284] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 09/22/2015] [Indexed: 11/13/2022] Open
Abstract
The diagnosis of extrapulmonary tuberculosis (EPTB) is difficult. In recent years, T-cell interferon-γ release assays (IGRAs) are widely used in diagnosing tuberculosis. The aim of this meta-analysis is to evaluate the diagnostic accuracy of body fluid IGRAs in diagnosing EPTB. The PubMed, EMBASE, Web of Science, and Cochrane bibliographies were searched for English language articles. 22 studies met the inclusion criteria. The pooled sensitivity and specificity of body fluid IGRAs for diagnosing EPTB were 0.87 [95% confidence interval (CI): 0.83–0.92] and 0.85 (95% CI: 0.79–0.90), respectively. For the fluid T-SPOT.TB, the pooled sensitivity and specificity were 0.92 (95% CI: 0.88–0.95) and 0.85 (95% CI: 0.78–0.91), respectively. The diagnostic odds ratio (DOR) of the fluid T-SPOT.TB was 46.99 (95% CI: 13.69–161.28) for tuberculosis pleurisy, 26.46 (95% CI: 11.38–61.56) for tuberculosis peritonitis, and 97.86 (95% CI: 25.31–378.45) for tuberculosis meningitis. The application of T-SPOT. TB in the diagnosis of EPTB performed better in the body fluid than in the blood. The diagnostic values of the fluid T-SPOT.TB varied for different fluid categories. However, the utility of T-SPOT.TB was limited due to its suboptimal accuracy and higher cost compared with conventional tests.
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Affiliation(s)
- Xiao-Xia Zhou
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.,Geriatric Department, Fu Xing hospital, Capital Medical University, Beijing, China
| | - Ya-Lan Liu
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Kan Zhai
- Medical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Huan-Zhong Shi
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.,Medical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zhao-Hui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.,Medical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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Pang CS, Shen YC, Tian PW, Zhu J, Feng M, Wan C, Wen FQ. Accuracy of the interferon-gamma release assay for the diagnosis of tuberculous pleurisy: an updated meta-analysis. PeerJ 2015; 3:e951. [PMID: 26038718 PMCID: PMC4451019 DOI: 10.7717/peerj.951] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 04/21/2015] [Indexed: 02/05/2023] Open
Abstract
Background and Objectives. The best method for diagnosing tuberculous pleurisy (TP) remains controversial. Since a growing number of publications focus on the interferon-gamma release assay (IGRA), we meta-analyzed the available evidence on the overall diagnostic performance of IGRA applied to pleural fluid and peripheral blood. Materials and Methods. PubMed and Embase were searched for relevant English papers up to October 31, 2014. Statistical analyses were performed using Stata and Meta-DiSc. Pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), positive predictive value (PPV), negative predictive value (NPV) and diagnostic odds ratio (DOR) were count. Summary receiver operating characteristic curves and area under the curve (AUC) were used to summarize the overall diagnostic performance. Results. Fifteen publications met our inclusion criteria and were included in the meta analysis. The following pooled estimates for diagnostic parameters of pleural IGRA were obtained: sensitivity, 0.82 (95% CI [0.79-0.85]); specificity, 0.87 (95% CI [0.84-0.90]); PLR, 4.94 (95% CI [2.60-9.39]); NLR, 0.22 (95% CI [0.13-0.38]); PPV, 0.91 (95% CI [0.85-0.96]); NPV, 0.79 (95% CI [0.71-0.85]); DOR, 28.37 (95% CI [10.53-76.40]); and AUC, 0.91. The corresponding estimates for blood IGRA were as follows: sensitivity, 0.80 (95% CI [0.76-0.83]); specificity, 0.70 (95% CI [0.65-0.75]); PLR, 2.48 (95% CI [1.95-3.17]); NLR, 0.30 (95% CI [0.24-0.37]); PPV, 0.79 (95% CI [0.60-0.87]); NPV, 0.75 (95% CI [0.62-0.83]); DOR, 9.96 (95% CI [6.02-16.48]); and AUC, 0.89. Conclusions. This meta analysis suggested that pleural IGRA has potential for serving as a complementary method for diagnosing TP; however, its cost, high turn around time, and sub-optimal performance make it unsuitable as a stand-alone diagnostic tool. Better tests for the diagnosis of TP are required.
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Affiliation(s)
- Cai-Shuang Pang
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University and Division of Pulmonary Diseases, State Key Laboratory of Biotherapy of China, China
| | - Yong-Chun Shen
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University and Division of Pulmonary Diseases, State Key Laboratory of Biotherapy of China, China
| | - Pan-Wen Tian
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University and Division of Pulmonary Diseases, State Key Laboratory of Biotherapy of China, China
| | - Jing Zhu
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University and Division of Pulmonary Diseases, State Key Laboratory of Biotherapy of China, China
| | - Mei Feng
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University and Division of Pulmonary Diseases, State Key Laboratory of Biotherapy of China, China
| | - Chun Wan
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University and Division of Pulmonary Diseases, State Key Laboratory of Biotherapy of China, China
| | - Fu-Qiang Wen
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University and Division of Pulmonary Diseases, State Key Laboratory of Biotherapy of China, China
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Interferon Gamma Release Assays for Diagnosis of Pleural Tuberculosis: a Systematic Review and Meta-Analysis. J Clin Microbiol 2015; 53:2451-9. [PMID: 25994163 DOI: 10.1128/jcm.00823-15] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 05/11/2015] [Indexed: 11/20/2022] Open
Abstract
The role of interferon gamma release assays (IGRAs), although established for identifying latent tuberculosis, is still evolving in the diagnosis of active extrapulmonary tuberculosis. We systematically evaluated the diagnostic performance of blood- and pleural fluid-based IGRAs in tuberculous pleural effusion (TPE). We searched the PubMed and Embase databases for studies evaluating the use of commercially available IGRAs on blood and/or pleural fluid samples for diagnosing TPE. The quality of the studies included was assessed through the QUADAS-2 tool. The pooled estimates of sensitivity and specificity with 95% confidence intervals (95% CI) were generated using a bivariate random-effects model and examined using forest plots and hierarchical summary receiver operating characteristic (HSROC) curves. Indeterminate IGRA results were included for sensitivity calculations. Heterogeneity was explored through subgroup analysis and meta-regression based on prespecified covariates. We identified 19 studies assessing the T.SPOT.TB and/or QuantiFERON assays. There were 20 and 14 evaluations, respectively, of whole-blood and pleural fluid assays, involving 1,085 and 727 subjects, respectively. There was only one good-quality study, and five studies used nonstandard assay thresholds. The pooled sensitivity and specificity for the blood assays were 0.77 (95% CI, 0.71 to 0.83) and 0.71 (95% CI, 0.65 to 0.76), respectively. The pooled sensitivity and specificity for the pleural fluid assays were 0.72 (95% CI, 0.55 to 0.84) and 0.78 (95% CI, 0.65 to 0.87), respectively. There was considerable heterogeneity; however, multivariate meta-regression did not identify any covariate with significant influence. There was no publication bias for blood assays. We conclude that commercial IGRAs, performed either on whole-blood or pleural fluid samples, have poor diagnostic accuracy in patients suspected to have TPE.
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New tuberculosis diagnostics and rollout. Int J Infect Dis 2015; 32:81-6. [DOI: 10.1016/j.ijid.2015.01.012] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 01/09/2015] [Accepted: 01/14/2015] [Indexed: 11/23/2022] Open
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Abstract
Tuberculosis (TB) in adults can present in a large number of ways. The lung is the predominant site of TB. Primary pulmonary TB should be distinguished from postprimary pulmonary TB, which is the most frequent TB manifestation in adults (70%-80% cases). Cough is common, although the chest radiograph often raises suspicion of disease. Sputum sampling is a key step in the diagnosis of TB, and invasive procedures such as bronchoscopy may be necessary to achieve adequate samples for diagnosis. Extrapulmonary involvement, which may present many years after exposure, occurs in a variable proportion of cases (20%-45%). This reflects the country of origin of patients and also the frequency of associated human immunodeficiency virus (HIV) coinfection. In the latter case, the presentation of TB is often nonspecific, and care needs to be taken to not miss the diagnosis. Anti-TB therapy should be given in line with proven (or assumed) drug resistance. In extrapulmonary TB, adjunctive therapeutic measures may be indicated; although in all cases, support is often required to ensure that people are able to complete treatment with minimal adverse events and maximal adherence to the prescribed regimen, and so reduce risk of future disease for themselves and others.
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Affiliation(s)
- Robert Loddenkemper
- Charité Universitätsmedizin Berlin, Department of Pneumology, HELIOS-Klinikum Emil von Behring, 14165 Lungenklinik Heckeshorn, Berlin, Germany
| | - Marc Lipman
- Respiratory & HIV Medicine, Royal Free London NHS Foundation Trust, University College London, London NW3 2QG, United Kingdom
| | - Alimuddin Zumla
- Division of Infection and Immunity, University College London, Consultant Infectious Diseases Physician, University College London Hospitals NHS Foundation Trust, London NW3 2PF, United Kingdom
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24
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Cohen LA, Light RW. Tuberculous Pleural Effusion. Turk Thorac J 2015; 16:1-9. [PMID: 29404070 DOI: 10.5152/ttd.2014.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 12/11/2014] [Indexed: 12/12/2022]
Abstract
When a patient presents with new pleural effusion, the diagnosis of tuberculous (TB) pleuritis should be considered. The patient is at risk for developing pulmonary or extrapulmonary TB if the diagnosis is not made. Between 3% and 25% of patients with TB will have TB pleuritis. The incidence of TB pleuritis is higher in patients who are human immunodeficiency virus (HIV)-positive. Pleural fluid is an exudate that usually has a predominance of lymphocytes. The easiest way to diagnose TB pleuritis in a patient with lymphocytic pleural effusion is to demonstrate a pleural fluid adenosine deaminase level above 40 IU/L. The treatment for TB pleuritis is the same as that for pulmonary TB. Tuberculous empyema is a rare occurrence, and the treatment is difficult.
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Affiliation(s)
- Leah A Cohen
- Internal Medicine Resident, Department of Medicine Vanderbilt University Medical Center, Nashville, TN, USA
| | - Richard W Light
- Division of Allergy, Pulmonary, and Critical Care Medicine Vanderbilt University Medical Center, Nashville, TN, USA
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Chegou NN, Hoek KGP, Kriel M, Warren RM, Victor TC, Walzl G. Tuberculosis assays: past, present and future. Expert Rev Anti Infect Ther 2014; 9:457-69. [DOI: 10.1586/eri.11.23] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Zhang L, Zhang Y, Shi X, Zhang Y, Deng G, Lalvani A, Liu X. Utility of T-cell interferon-γ release assays for diagnosing tuberculous serositis: a prospective study in Beijing, China. PLoS One 2014; 9:e85030. [PMID: 24416336 PMCID: PMC3887014 DOI: 10.1371/journal.pone.0085030] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Accepted: 11/21/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Diagnosis of tuberculous serositis remains a challenge. The aim of this study was to evaluate the diagnostic efficiency of T-SPOT.TB on serous effusion mononuclear cells (SEMC) for diagnosing tuberculous serositis in a high TB burden area. METHODS The present prospective study enrolled patients with suspected tuberculous serositis in a tertiary referral hospital in Beijing, China, to investigate the diagnostic sensitivity, specificity, predictive value (PV), and likelihood ratio(LR) of these tests. Clinical assessment, T-SPOT.TB on SEMC, and T-SPOT.TB on PBMC were performed. Test results were compared with the final confirmed diagnosis. RESULTS Of the 187 participants, 74 (39.6%) were microbiologically or clinically diagnosed as tuberculous serositis and 93(49.7%) were ruled out. The remaining 20 (10.7%) patients were clinically indeterminate and excluded from the final analysis. Compared to that on PBMC, T-SPOT.TB on SEMC showed higher sensitivity (91.9%vs73.0%, P = 0.002), specificity (87.1%vs.73.1%, P = 0.017), PPV (85.0%vs.68.4%, P = 0.013), NPV (93.1%vs.77.3%, P = 0.003), LR+ (7.12vs.2.72) and LR- (0.09vs.0.37), respectively. The frequencies of spot forming cells (SFCs) for T-SPOT.TB on SEMC were 636 per million SEMC (IQR, 143-3443) in patients with tuberculous serositis, which were 4.6-fold (IQR, 1.3-14.3) higher than those of PBMC. By ROC curve analysis, a cut-off value of 56 SFCs per million SEMC for T-SPOT.TB on SEMC showed a sensitivity of 90.5% and specificity of 89.2% for the diagnosis of tuberculous serositis. CONCLUSIONS T-SPOT.TB on SEMC could be an accurate diagnostic method for tuberculous serositis in TB endemic settings. And 56 SFCs per million SEMC might be the optimal cut-off value to diagnose tuberculous serositis.
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Affiliation(s)
- Lifan Zhang
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Clinical Epidemiology Unit, Peking Union Medical College, International Clinical Epidemiology Network, Beijing, China
| | - Yueqiu Zhang
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiaochun Shi
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yao Zhang
- Clinical Epidemiology Unit, Peking Union Medical College, International Clinical Epidemiology Network, Beijing, China
| | - Guohua Deng
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ajit Lalvani
- Department of Respiratory Medicine, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Xiaoqing Liu
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Clinical Epidemiology Unit, Peking Union Medical College, International Clinical Epidemiology Network, Beijing, China
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Differential expression of host biomarkers in saliva and serum samples from individuals with suspected pulmonary tuberculosis. Mediators Inflamm 2013; 2013:981984. [PMID: 24327799 PMCID: PMC3845251 DOI: 10.1155/2013/981984] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Accepted: 09/18/2013] [Indexed: 12/11/2022] Open
Abstract
The diagnosis of tuberculosis remains challenging in individuals with difficulty in providing good quality sputum samples such as children. Host biosignatures of inflammatory markers may be valuable in such cases, especially if they are based on more easily obtainable samples such as saliva. To explore the potential of saliva as an alternative sample in tuberculosis diagnostic/biomarker investigations, we evaluated the levels of 33 host markers in saliva samples from individuals presenting with pulmonary tuberculosis symptoms and compared them to those obtained in serum. Of the 38 individuals included in the study, tuberculosis disease was confirmed in 11 (28.9%) by sputum culture. In both the tuberculosis cases and noncases, the levels of most markers were above the minimum detectable limit in both sample types, but there was no consistent pattern regarding the ratio of markers in serum/saliva. Fractalkine, IL-17, IL-6, IL-9, MIP-1 β , CRP, VEGF, and IL-5 levels in saliva and IL-6, IL-2, SAP, and SAA levels in serum were significantly higher in tuberculosis patients (P < 0.05). These preliminary data indicate that there are significant differences in the levels of host markers expressed in saliva in comparison to those expressed in serum and that inflammatory markers in both sample types are potential diagnostic candidates for tuberculosis disease.
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Keng LT, Shu CC, Chen JYP, Liang SK, Lin CK, Chang LY, Chang CH, Wang JY, Yu CJ, Lee LN. Evaluating pleural ADA, ADA2, IFN-γ and IGRA for diagnosing tuberculous pleurisy. J Infect 2013; 67:294-302. [DOI: 10.1016/j.jinf.2013.05.009] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 05/21/2013] [Accepted: 05/25/2013] [Indexed: 10/26/2022]
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Eldin EN, Omar A, Khairy M, Mekawy AHM, Ghanem MK. Diagnostic value of ex vivo pleural fluid interferon-gamma versus adapted whole-blood quantiferon-TB gold in tube assays in tuberculous pleural effusion. Ann Thorac Med 2012. [PMID: 23189099 PMCID: PMC3506102 DOI: 10.4103/1817-1737.102181] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND: Noninvasive diagnosis of pleural tuberculosis (TB) remains a challenge due to the paucibacillary nature of the disease. As Mycobacterium tuberculosis (MTB)-specific T cells are recruited into pleural space in TB effusion; their indirect detection may provide useful clinical information. OBJECTIVES: Evaluation of pleural fluid interferon (INF)-γ levels vs Quantiferon–TB Gold In tube assay (QFT- IT) in blood and its adapted variants, using pleural fluid or isolated pleural fluid cells in the diagnosis of pleural TB. METHODS: Thirty-eight patients with pleural effusion of unknown etiology presented at Assiut University Hospital, Egypt, were recruited. Blood and pleural fluid were collected at presentation for INF-γ assays. Ex vivo pleural fluid INF-γ levels, QFT-IT in blood and its adapted variants were compared with final diagnosis as confirmed by other tools including blind and/or thoracoscopic pleural biopsy. RESULTS: The final clinical diagnosis was TB in 20 (53%), malignancy in 10 (26%), and effusion due to other causes in eight patients (21%). Ex vivo pleural fluid INF-γ levels accurately identified TB in all patients and were superior to the QFT-IT assays using blood or pleural fluid (70 and 78% sensitivity, with 60 and 83% specificity, respectively). QFT-IT assay applied to isolated pleural fluid cells had 100% sensitivity and 72% specificity. The optimal cut-off obtained with ROC analysis was 0.73 for TB Gold assay in blood assay, 0.82 IU/ml for the cultured pleural fluid assay, and 0.94 for isolated pleural cells assay. CONCLUSION: The ex vivo pleural fluid INF-γ level is an accurate marker for the diagnosis of pleural TB. QFT- IT assay in peripheral blood or its adapted versions of the assay using pleural fluid and/or washed pleural fluid cells had no diagnostic advantage over pleural fluid INF-γ in the diagnosis of pleural TB.
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Affiliation(s)
- Eman N Eldin
- Department of Clinical Pathology, Assiut University Hospital, Egypt
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Kang JY, Rhee CK, Kang NH, Kim JS, Yoon HK, Song JS. Clinical Utility of Two Interferon-gamma Release Assays on Pleural Fluid for the Diagnosis of Tuberculous Pleurisy. Tuberc Respir Dis (Seoul) 2012; 73:143-50. [PMID: 23166547 PMCID: PMC3492399 DOI: 10.4046/trd.2012.73.3.143] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Revised: 01/30/2012] [Accepted: 08/02/2012] [Indexed: 11/24/2022] Open
Abstract
Background The release of interferon-gamma (IFN-γ) by T lymphocytes increases after rechallenge with Mycobacterium tuberculosis antigen, especially, at a localized site of tuberculosis (TB) infection. We aimed to compare the clincial efficacy of two commercial IFN-γ release assays from pleural fluid for the diagnosis in tuberculous pleurisy. Methods We performed T-SPOT.TB and QuantiFERON-TB Gold tests simultaneously on pleural fluid and peripheral blood samples from patients with pleural effusion, in South Korea, an area with intermediate TB burden. Results Thirty-six patients were enrolled prospectively, and tuberculous pleurisy was found in 21 patients. Both the numbers of IFN-γ secreting T cells and the concentration of IFN-γ were greater in the pleural tuberculous group, comparing with the non-tuberculous group. Moreover, in the tuberculous group, there was a significant difference in IFN-γ producing spot-forming cells using the T-SPOT.TB method between pleural fluid and peripheral blood. The receiver operating characteristic (ROC) curve, was the greatest for pleural fluid T-SPOT.TB test, followed by peripheral blood T-SPOT.TB test, peripheral blood QuantiFERON-TB Gold test, and pleural fluid QuantiFERON-TB Gold test (area under the ROC curve of 0.956, 0.890, 0.743, and 0.721, respectively). The T-SPOT.TB assay produced less indeterminate results than did QuantiFERON-TB Gold assay in both pleural fluid and peripheral blood. Conclusion These findings suggest that the pleural fluid T-SPOT.TB test could be the most useful test among the IFN-γ release assays for diagnosing tuberculous pleurisy in an area with an intermediate prevalence of TB infection.
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Affiliation(s)
- Ji Young Kang
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
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Fan L, Chen Z, Hao XH, Hu ZY, Xiao HP. Interferon-gamma release assays for the diagnosis of extrapulmonary tuberculosis: a systematic review and meta-analysis. ACTA ACUST UNITED AC 2012; 65:456-66. [PMID: 22487051 DOI: 10.1111/j.1574-695x.2012.00972.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Revised: 04/02/2012] [Accepted: 04/02/2012] [Indexed: 11/30/2022]
Abstract
Interferon -gamma release assays (IGRAs) provide a new diagnostic method for Mycobacterium tuberculosis (TB) infection. However, the diagnostic value of IGRAs for extrapulmonary TB (EPTB) has not been clarified. We searched several databases and selected papers with strict inclusion criteria, evaluated the evidence of commercially available IGRAs (QuantiFERON(®) -TB Gold QFT-G or QFT-GIT and T-SPOT(®) .TB) on blood and the tuberculin skin test (TST) using random effects models. Twenty studies with 1711 patients were included. After excluding indeterminate results, pooled sensitivity for the diagnosis of EPTB was 72% [95% confidence interval (CI) 65-79%] for QFT-G or GIT and 90% (95% CI, 86-93%) for T-SPOT; in high-income countries the sensitivity of QFT-G or GIT (79%, 95% CI 72-86%) was much higher than that (29%, 95% CI 14-48%) in low/middle-income countries. Pooled specificity for EPTB was 82% (95% CI 78-87%) for QFT-G or GIT and 68% (95% CI 64-73%) for T-SPOT. Pooled sensitivity of TST from four studies in high-income countries was lower than that of IGRAs. T-SPOT was more sensitive in detecting EPTB than QFT-G or GIT and TST. However, both IGRAs and TST have similar specificity for EPTB. IGRAs have limited value as diagnostic tools to screen and rule out EPTB, especially in low/middle-income countries. The immune status of patients does not affect the diagnostic accuracy of IGRAs for EPTB.
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Affiliation(s)
- Lin Fan
- Tuberculosis Center for Diagnosis and Treatment, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
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Infection dynamics and response to chemotherapy in a rabbit model of tuberculosis using [¹⁸F]2-fluoro-deoxy-D-glucose positron emission tomography and computed tomography. Antimicrob Agents Chemother 2012; 56:4391-402. [PMID: 22687508 DOI: 10.1128/aac.00531-12] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
With a host of new antitubercular chemotherapeutics in development, methods to assess the activity of these agents beyond mouse efficacy are needed to prioritize combinations for clinical trials. Lesions in Mycobacterium tuberculosis-infected rabbits are hypoxic, with histopathologic features that closely resemble those of human tuberculous lesions. Using [(18)F]2-fluoro-deoxy-d-glucose ([(18)F]FDG) positron emission tomography-computed tomography (PET-CT) imaging, we studied the dynamics of tuberculosis infection in rabbits, revealing an initial inflammatory response followed by a consolidative chronic disease. Five weeks after infection, as much as 23% of total lung volume was abnormal, but this was contained and to some extent reversed naturally by 9 weeks. During development of this chronic state, individual lesions in the same animal had very different fates, ranging from complete resolution to significant progression. Lesions that remained through the initial stage showed an increase in volume and tissue density over time by CT. Initiation of chemotherapy using either isoniazid (INH) or rifampin (RIF) during chronic infection reduced bacterial load with quantitative changes in [(18)F]FDG uptake, lesion density and total lesion volume measured by CT. The [(18)F]FDG PET uptake in lesions was significantly reduced with as little as 1 week of treatment, while the volume and density of lesions changed more slowly. The results from this study suggest that rabbits may be a useful surrogate species for evaluating novel chemotherapies and understanding changes in both PET and CT scans in human clinical trials.
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Chegou NN, Essone PN, Loxton AG, Stanley K, Black GF, van der Spuy GD, van Helden PD, Franken KL, Parida SK, Klein MR, Kaufmann SHE, Ottenhoff THM, Walzl G. Potential of host markers produced by infection phase-dependent antigen-stimulated cells for the diagnosis of tuberculosis in a highly endemic area. PLoS One 2012; 7:e38501. [PMID: 22693640 PMCID: PMC3367928 DOI: 10.1371/journal.pone.0038501] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 05/10/2012] [Indexed: 11/25/2022] Open
Abstract
Background Recent interferon gamma (IFN-γ)-based studies have identified novel Mycobacterium tuberculosis (M.tb) infection phase-dependent antigens as diagnostic candidates. In this study, the levels of 11 host markers other than IFN-γ, were evaluated in whole blood culture supernatants after stimulation with M.tb infection phase-dependent antigens, for the diagnosis of TB disease. Methodology and Principal Findings Five M.tb infection phase-dependent antigens, comprising of three DosR-regulon-encoded proteins (Rv2032, Rv0081, Rv1737c), and two resucitation promoting factors (Rv0867c and Rv2389c), were evaluated in a case-control study with 15 pulmonary TB patients and 15 household contacts that were recruited from a high TB incidence setting in Cape Town, South Africa. After a 7-day whole blood culture, supernatants were harvested and the levels of the host markers evaluated using the Luminex platform. Multiple antigen-specific host markers were identified with promising diagnostic potential. Rv0081-specific levels of IL-12(p40), IP-10, IL-10 and TNF-α were the most promising diagnostic candidates, each ascertaining TB disease with an accuracy of 100%, 95% confidence interval for the area under the receiver operating characteristics plots, (1.0 to 1.0). Conclusions Multiple cytokines other than IFN-γ in whole blood culture supernatants after stimulation with M.tb infection phase-dependent antigens show promise as diagnostic markers for active TB. These preliminary findings should be verified in well-designed diagnostic studies employing short-term culture assays.
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Affiliation(s)
- Novel N Chegou
- Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Health Sciences, Stellenbosch University, Tygerberg, South Africa.
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A systematic review of the epidemiology, immunopathogenesis, diagnosis, and treatment of pleural TB in HIV-infected patients. Clin Dev Immunol 2012; 2012:842045. [PMID: 22474483 PMCID: PMC3312223 DOI: 10.1155/2012/842045] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Revised: 12/14/2011] [Accepted: 12/29/2011] [Indexed: 12/20/2022]
Abstract
BACKGROUND High HIV burden countries have experienced a high burden of pleural TB in HIV-infected patients. OBJECTIVE To review the epidemiology, immunopathogenesis, diagnosis, and treatment of pleural TB in HIV-infected patients. METHODS A literature search from 1950 to June 2011 in MEDLINE was conducted. RESULTS Two-hundred and ninety-nine studies were identified, of which 30 met the inclusion criteria. The immunopathogenesis as denoted by cells and cytokine profiles is distinctly different between HIV and HIV-uninfected pleural TB disease. Adenosine deaminase and interferon gamma are good markers of pleural TB disease even in HIV-infected patients. HIV-uninfected TB suspects with pleural effusions commonly have a low yield of TB organisms however the evidence suggests that in dually infected patients smear and cultures have a higher yield. The Gene Xpert MTB/RIF assay has significant potential to improve the diagnosis of pleural TB in HIV-positive patients. CONCLUSIONS Pleural TB in HIV-infected patients has a different immunopathogenesis than HIV-uninfected pleural TB and these findings in part support the differences noted in this systematic review. Research should focus on developing an interferon gamma-based point of care diagnostic test and expansion of the role of Gene Xpert in the diagnosis of pleural TB.
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Achkar JM, Lawn SD, Moosa MYS, Wright CA, Kasprowicz VO. Adjunctive tests for diagnosis of tuberculosis: serology, ELISPOT for site-specific lymphocytes, urinary lipoarabinomannan, string test, and fine needle aspiration. J Infect Dis 2011; 204 Suppl 4:S1130-41. [PMID: 21996695 PMCID: PMC3192548 DOI: 10.1093/infdis/jir450] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
The diagnostic gold standard for active tuberculosis (TB) is the detection of Mycobacterium tuberculosis (MTB) by culture or molecular methods. However, despite its limited sensitivity, sputum smear microscopy is still the mainstay of TB diagnosis in resource-limited settings. Consequently, diagnosis of smear-negative pulmonary and extrapulmonary TB remains challenging in such settings. A number of novel or alternative techniques could provide adjunctive diagnostic use in the context of difficult-to-diagnose TB. These may be especially useful in certain patient groups such as persons infected with human immunodeficiency virus (HIV) and children, who are disproportionably affected by smear-negative and extrapulmonary disease and who are also most adversely affected by delays in TB diagnosis and treatment. We review a selection of these methods that are independent of nucleic acid amplification techniques and could largely be implemented in resource-limited settings in current or adapted versions. Specifically, we discuss the diagnostic use and potential of serologic tests based on detection of antibodies to MTB antigens; interferon gamma release assays using site-specific lymphocytes; detection of lipoarabinomannan, a glycolipid of MTB, in urine; the string test, a novel technique to retrieve lower respiratory tract samples; and fine needle aspiration biopsy of lymph nodes.
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Affiliation(s)
- Jacqueline M Achkar
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York 10461, USA.
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Clinical utility of QuantiFERON-TB GOLD In-Tube and tuberculin skin test in patients with tuberculous pleural effusions. Diagn Microbiol Infect Dis 2011; 71:263-6. [PMID: 21885230 DOI: 10.1016/j.diagmicrobio.2011.06.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2011] [Revised: 06/18/2011] [Accepted: 06/27/2011] [Indexed: 11/20/2022]
Abstract
Interferon gamma release assays are used for diagnosing latent tuberculosis (TB); however, their role in diagnosing tuberculous pleural effusion (TPE) is not defined. The aim of this study was to evaluate the usefulness of the QuantiFERON-TB Gold In-Tube assay (QFT-IT) and compare this assay with the tuberculin skin test (TST) for diagnosing TPE in settings where tuberculosis is endemic and bacillus Calmette-Guérin vaccination is mandatory. The TST and QFT-IT test were conducted prospectively with 101 patients presenting with clinically suspected TPE. Of the 97 evaluable subjects, 54 had TPE. The sensitivity, specificity, positive predictive value, and negative predictive value were, respectively, 76.9%, 61.1%, 74.1%, and 64.7% for QFT-IT; 72.5%, 71.7%, 77.1%, and 66.7% for TST; and 83.7%, 45.7%, 68.3%, and 66.7% for QFT-IT plus TST. Thus, the QFT-IT test may be more useful than the TST for diagnosing TPE. Although the combination of QFT-IT and TST had higher sensitivity, it had poor specificity owing to the high prevalence of latent TB in our setting.
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Lai CC, Tan CK, Lin SH, Liao CH, Huang YT, Hsueh PR. Diagnostic performance of whole-blood interferon-γ assay and enzyme-linked immunospot assay for active tuberculosis'. Diagn Microbiol Infect Dis 2011; 71:139-43. [PMID: 21840675 DOI: 10.1016/j.diagmicrobio.2011.05.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2011] [Revised: 05/23/2011] [Accepted: 05/31/2011] [Indexed: 10/17/2022]
Abstract
The aim of this study was to compare the diagnostic performance of 2 interferon-γ release assays, an enzyme-linked immunospot assay (T-SPOT.TB; Oxford Immunotec Ltd., Oxford, UK) and the QuantiFERON-TB Gold in-Tube assay (QFT-GIT; Cellestis Ltd., Carnegie, Australia), in patients with suspected active tuberculosis (TB). From October 2009 to October 2011, a total of 200 patients with suspected TB were enrolled. Clinical and microbiological characteristics of the patients were collected and blood samples were obtained for T-SPOT.TB and QFT-GIT assays. Among the 200 subjects, 98 (49%) had culture-confirmed TB, 18 (9%) had probable TB, and the remaining 84 (42%) subjects did not have TB. The sensitivity, specificity, positive predictive value, and negative predictive value for active TB diagnosis by the T SPOT. TB were 83%, 71%, 81%, and 75%, respectively. For QFT-GIT, the sensitivity, specificity, positive predictive value, and negative predictive value for active TB diagnosis were 66%, 76%, 80%, and 62%, respectively. The QFT-GIT assay resulted in more indeterminate and false-negative results than the T-SPOT.TB assay, especially in immunocompromised patients. In conclusion, T-SPOT.TB had a higher sensitivity and resulted in fewer indeterminate results than the QFT-GIT assay for diagnosing active TB.
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Affiliation(s)
- Chih-Cheng Lai
- Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying, Tainan, Taiwan, 736
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Zhou Q, Chen YQ, Qin SM, Tao XN, Xin JB, Shi HZ. Diagnostic accuracy of T-cell interferon-γ release assays in tuberculous pleurisy: a meta-analysis. Respirology 2011; 16:473-80. [PMID: 21299686 DOI: 10.1111/j.1440-1843.2011.01941.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND OBJECTIVE The diagnosis of tuberculous pleurisy by analysis of pleural fluid using standard diagnostic tools is difficult. Recently, T-cell interferon-γ release assays (IGRA) have been introduced for the diagnosis of tuberculous pleurisy. The aim of the present meta-analysis was to establish the overall diagnostic accuracy of IGRA on both pleural fluid and peripheral blood, for diagnosing tuberculous pleurisy. METHODS A systematic review was performed of English language publications. Sensitivity, specificity and other measures of the accuracy of IGRA for the diagnosis tuberculous pleurisy using both pleural fluid and blood were pooled using a random-effects model or a fixed-effects model. Receiver operating characteristic curves were used to summarize overall test performance. RESULTS Seven out of eight studies met the inclusion criteria. The summary estimates of sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, positive predictive value, negative predictive value and diagnostic odds ratio were, for pleural fluid: 0.75, 0.82, 3.49, 0.24, 0.85, 0.70 and 19.04, respectively; and for blood: 0.80, 0.72, 2.86, 0.28, 0.78, 0.74 and 11.06, respectively. CONCLUSIONS As almost 20% of non-tuberculosis patients would be erroneously treated for tuberculosis and 25% of patients with tuberculous pleurisy would be missed, pleural fluid IGRA are not useful for the clinical diagnosis of tuberculous pleurisy.
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Affiliation(s)
- Qiong Zhou
- Department of Respiratory Diseases, Union Hospital, Key Lab of Pulmonary Diseases of Health Ministry, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Ates G, Yildiz T, Ortakoylu MG, Ozekinci T, Erturk B, Akyildiz L, Caglar E. Adapted T Cell Interferon-Gamma Release Assay for the Diagnosis of Pleural Tuberculosis. Respiration 2011; 82:351-7. [DOI: 10.1159/000323184] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Accepted: 11/25/2010] [Indexed: 11/19/2022] Open
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Kim YY, Lee J, Lee YJ, Lee SY, Lee YH, Choi KJ, Hwangbo Y, Cha SI, Park JY, Jung TH, Park JS, Kim CH. Sensitivity of Whole-Blood Interferon-Gamma Release Assay According to the Severity and the Location of Disease in Patients with Active Tuberculosis. Tuberc Respir Dis (Seoul) 2011. [DOI: 10.4046/trd.2011.70.2.125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Yi Young Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jaehee Lee
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Yoon Jee Lee
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - So Yeon Lee
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Yong Hun Lee
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Keum Ju Choi
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Yup Hwangbo
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Seung Ick Cha
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jae Yong Park
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Tae Hoon Jung
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jun Sik Park
- Department of Otorhinolaryngology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Chang Ho Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
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Losi M, Bocchino M, Matarese A, Bellofiore B, Roversi P, Rumpianesi F, Alma M, Chiaradonna P, Del Giovane C, Altieri A, Richeldi L, Sanduzzi A. Role of the Quantiferon-TB Test in Ruling Out Pleural Tuberculosis: A Multi-Centre Study. Int J Immunopathol Pharmacol 2011; 24:159-65. [DOI: 10.1177/039463201102400118] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Diagnosing pleural tuberculosis (plTB) might be difficult due to limited sensitivity of conventional microbiology tools. As M. tuberculosis (MTB)-specific T cells are recruited into pleural space in plTB, their detection may provide useful clinical information. To this aim, in addition to standard diagnostic tests, we used the QuantiFERON-TB Gold In-Tube (QFT-IT) test in blood and pleural effusion (PE) samples from 48 patients with clinical suspicion of plTB, 18 (37.5%) of whom had confirmed plTB. Four of them (22.2%) tested positive with a nucleic acid amplification test for MTB. The tuberculin skin test was positive in most confirmed plTB cases (88.9%). Positive QFT-IT tests were significantly more frequent in patients with confirmed plTB, as compared to patients with an alternative diagnosis, both in blood (77.7 vs 36.6%, p=0.006) and in PE samples (83.3% vs 46.6%, p=0.02). In addition, both blood and PE MTB-stimulated IFN-γ levels were significantly higher in plTB patients (p=0.03 and p=0.0049 vs non-plTB, respectively). In blood samples, QFT-IT had 77.8% sensitivity and 63.3% specificity, resulting in 56.0% positive (PPV) and 82.6% negative (NPV) predictive values. On PE, QFT-IT sensitivity was 83.3% and specificity 53.3% (PPV 51.7% and NPV 84.2%). The optimal AUC-derived cut-off for MTB-stimulated pleural IFN-γ level was 3.01 IU/mL (77.8% sensitivity, 80% specificity, PPV 68.4% and NPV 82.8%). These data suggest that QFT-IT might have a role in ruling out plTB in clinical practice.
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Affiliation(s)
- M. Losi
- Section of Respiratory Diseases, Department of Oncology, Haematology and Respiratory Diseases, University of Modena and Reggio Emilia, Modena
| | - M. Bocchino
- Section of Respiratory Diseases, Department of Experimental and Clinical Medicine, “Federico II” University of Naples, Naples
| | - A. Matarese
- Section of Respiratory Diseases, Department of Experimental and Clinical Medicine, “Federico II” University of Naples, Naples
| | - B. Bellofiore
- Section of Respiratory Diseases, Department of Experimental and Clinical Medicine, “Federico II” University of Naples, Naples
| | - P. Roversi
- Section of Respiratory Diseases, Department of Oncology, Haematology and Respiratory Diseases, University of Modena and Reggio Emilia, Modena
| | - F. Rumpianesi
- Department of Microbiology and Virology, University of Modena and Reggio Emilia, Modena
| | - M.G. Alma
- Microbiology and Virology Service, S. Camillo-Forlanini Hospital, Rome
| | - P. Chiaradonna
- Division of Broncho-pneumology and Tisiology, S. Camillo-Forlanini Hospital, Rome
| | - C. Del Giovane
- Section of Statistics, Department of Oncology, Haematology and Respiratory Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - A.M. Altieri
- Microbiology and Virology Service, S. Camillo-Forlanini Hospital, Rome
| | - L. Richeldi
- Section of Respiratory Diseases, Department of Oncology, Haematology and Respiratory Diseases, University of Modena and Reggio Emilia, Modena
| | - A. Sanduzzi
- Section of Respiratory Diseases, Department of Experimental and Clinical Medicine, “Federico II” University of Naples, Naples
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Cheng SL, Wang HC, Yang PC, Kuo SH. Risk factors for high mesothelial cell counts in HIV-negative patients with tuberculous pleural effusion. J Formos Med Assoc 2010; 109:456-62. [PMID: 20610147 DOI: 10.1016/s0929-6646(10)60077-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2009] [Revised: 07/06/2009] [Accepted: 09/08/2009] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND/PURPOSE Higher mesothelial cell counts (HM) greater than 5% of total cell counts in tuberculous pleural effusions (TBPE) have been described in human immunodeficiency virus (HIV)-infected patients, however the nature and risk factors in HIV-negative patients with TBPE are unknown. The purpose of the study was to characterize the clinical manifestation of HM in HIV-negative patients with TBPE and evaluate the risk factors of developing HM-TBPE. METHODS This retrospective study was undertaken in HIV-negative patients with TBPE from the Far Eastern Memorial Hospital Tuberculosis database. The cytologist and examining specialist differentiated and quantified the cell counts. HM-TBPE was defined when more than 5% of total cell counts in the pleural fluid were mesothelial cells. Multivariate analysis was calculated with stepwise logistic regression for HM-TBPE risk factors. RESULTS Nineteen patients were diagnosed as HM-TBPE, while 30 were diagnosed with lower mesothelial cell counts TBPE (LM-TBPE). Compared with LM-TBPE patients, those with HM-TBPE had significantly decreased hemoglobin and serum albumin levels (p<0.05). Organ dysfunction such as congestive heart failure, liver cirrhosis and renal failure was significantly more common in patients with HM-TBPE (47.4%) than in patients with LM-TBPE (13.3%; p=0.01). Multivariate analysis revealed that independent risk factors for developing HM-TBPE included hypoalbuminemia (odds ratio =1.6; 95% confidence interval = 1.1-13.8) and the presence of organ dysfunction (odds ratio =4.5; 95% confidence interval = 1.4-17.5). CONCLUSION Baseline hypoalbuminemia and comorbidities were independent risk factors for development of HM-TBPE in HIV-negative patients. Mesothelial cell counts should not be used alone in the diagnosis of TBPE. An understanding of the organ dysfunction associated with HM-TBPE in HIV-negative patients could avoid delayed diagnosis and treatment of tuberculosis.
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Affiliation(s)
- Shih-Lung Cheng
- Department of Internal Medicine, Far Eastern Memorial Hospital, Taipei, Taiwan
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Use of pleural fluid levels of adenosine deaminase and interferon gamma in the diagnosis of tuberculous pleuritis. Curr Opin Pulm Med 2010; 16:367-75. [DOI: 10.1097/mcp.0b013e32833a7154] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Mishra EK, Davies RJO. Advances in the investigation and treatment of pleural effusions. Expert Rev Respir Med 2010; 4:123-33. [PMID: 20387298 DOI: 10.1586/ers.09.67] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Pleural effusions present a challenge for both diagnosis and treatment. They are a commonly presenting problem of a wide range of local and systemic potentially life threatening diseases and cause significant breathlessness. Significant advances have been made in the last 5 years in the diagnostic pathway and management options. This article reviews recent developments in the investigation of pleural effusions, particularly in pleural fluid analysis, biomarkers, imaging and pleural biopsy, and in the treatment of pleural infection and both malignant and benign effusions, including the use of indwelling pleural catheters. Although significant recent advances have been made in the management of pleural effusions, there the need still remains for further research if we are to reduce the morbidity and mortality caused by pleural effusions.
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Affiliation(s)
- Eleanor K Mishra
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LJ, UK.
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Place S, Verscheure V, de San N, Hougardy JM, Schepers K, Dirix V, Dediste A, Michel O, Drowart A, Allard SD, Doherty TM, Lecher S, Locht C, Mascart F. Heparin-binding, hemagglutinin-specific IFN-gamma synthesis at the site of infection during active tuberculosis in humans. Am J Respir Crit Care Med 2010; 182:848-54. [PMID: 20508213 DOI: 10.1164/rccm.201001-0083oc] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
RATIONALE Tuberculosis (TB) remains a major cause of mortality. A better understanding of the immune responses to mycobacterial antigens may be helpful to develop improved vaccines and diagnostics. OBJECTIVES The mycobacterial antigen heparin-binding hemagglutinin (HBHA) induces strong IFN-γ responses by circulating lymphocytes from subjects latently infected with Mycobacterium tuberculosis, and low responses associated with CD4(+) regulatory T (Treg) cells in patients with TB. Here, we investigated HBHA-specific IFN-γ responses at the site of the TB disease. METHODS Bronchoalveolar lavages, pleural fluids, and blood were prospectively collected from 61 patients with a possible diagnosis of pulmonary or pleural TB. HBHA-specific IFN-γ production was analyzed by flow cytometry and ELISA. The suppressive effect of pleural Treg cells was investigated by depletion experiments. MEASUREMENTS AND MAIN RESULTS The percentages of HBHA-induced IFN-γ(+) alveolar and pleural lymphocytes were higher for pulmonary (P < 0.0001) and for pleural (P < 0.01) TB than for non-TB controls. Local CD4(+) and CD8(+) T cells produced the HBHA-specific IFN-γ. This local secretion was not suppressed by Treg lymphocytes, contrasting with previously reported data on circulating lymphocytes. CONCLUSIONS Patients with TB display differential effector and regulatory T-cell responses to HBHA in local and circulating lymphocytes with a predominant effector CD4(+) and CD8(+) response locally, compared with a predominant Treg response among circulating lymphocytes. These findings may be helpful for the design of new vaccines against TB, and the detection of HBHA-specific T cells at the site of the infection may be a promising tool for the rapid diagnosis of active TB.
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Affiliation(s)
- Sammy Place
- Laboratory of Vaccinology and Mucosal Immunity, Hôpital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
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Abstract
Tuberculosis (TB) is an international public health priority and kills almost two million people annually. TB is out of control in Africa due to increasing poverty and HIV coinfection, and drug-resistant TB threatens to destabilize TB control efforts in several regions of the world. Existing diagnostic tools and therapeutic interventions for TB are suboptimal. Thus, new vaccines, immunotherapeutic interventions and diagnostic tools are urgently required to facilitate TB control efforts. An improved understanding of the immunopathogenesis of TB can facilitate the identification of correlates of immune protection, the design of effective vaccines, the rational selection of immunotherapeutic agents, the evaluation of new drug candidates, and drive the development of new immunodiagnostic tools. Here we review the immunology of TB with a focus on aspects that are clinically and therapeutically relevant. An immunologically orientated approach to tackling TB can only succeed with concurrent efforts to alleviate poverty and reduce the global burden of HIV.
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Affiliation(s)
- Keertan Dheda
- Division of Pulmonology and Clinical Immunology & UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa.
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47
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Abstract
The possibility of tuberculous pleuritis should be considered in every patient with an undiagnosed pleural effusion, for if this diagnosis is not made the patient will recover only to have a high likelihood of subsequently developing pulmonary or extrapulmonary tuberculosis Between 3% and 25% of patients with tuberculosis will have tuberculous pleuritis. The incidence of pleural tuberculosis is higher in patients who are HIV positive. Tuberculous pleuritis usually presents as an acute illness with fever, cough and pleuritic chest pain. The pleural fluid is an exudate that usually has predominantly lymphocytes. Pleural fluid cultures are positive for Mycobacterium tuberculosis in less than 40% and smears are virtually always negative. The easiest way to establish the diagnosis of tuberculous pleuritis in a patient with a lymphocytic pleural effusion is to generally demonstrate a pleural fluid adenosine deaminase level above 40 U/L. Lymphocytic exudates not due to tuberculosis almost always have adenosine deaminase levels below 40 U/L. Elevated pleural fluid levels of gamma-interferon also are virtually diagnostic of tuberculous pleuritis in patients with lymphocytic exudates. In questionable cases the diagnosis can be established by demonstrating granulomas or organisms on tissue specimens obtained via needle biopsy of the pleura or thoracoscopy. The chemotherapy for tuberculous pleuritis is the same as that for pulmonary tuberculosis.
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Affiliation(s)
- Richard W Light
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University, Nashville, Tennessee 37232-2650, USA.
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Diel R, Loddenkemper R, Nienhaus A. Evidence-based comparison of commercial interferon-gamma release assays for detecting active TB: a metaanalysis. Chest 2009; 137:952-68. [PMID: 20022968 DOI: 10.1378/chest.09-2350] [Citation(s) in RCA: 269] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Test accuracy of interferon-gamma release assays (IGRAs) for diagnosing TB differs when using older or precommercial tools and inconsistent diagnostic criteria. This metaanalysis critically appraises studies investigating sensitivity and specificity of the commercial T-Spot.TB and the QuantiFERON-TB Gold In-Tube Assay (QFT-IT) among definitely confirmed TB cases. We searched Medline, EMBASE, and Cochrane bibliographies of relevant articles. Sensitivities, specificities, and indeterminate rates were pooled using a fixed effect model. Sensitivity of the tuberculin skin test (TST) was evaluated in the context of IGRA studies. In addition, the rates of indeterminates of both IGRAs were assessed. The pooled sensitivity of TST was 70% (95% CI, 0.67-0.72) compared with 81% (95% CI, 0.78-0.83) for the QFT-IT and 88% (95% CI, 0.85-0.90) for the T-Spot.TB. Sensitivity increased to 84% (95%CI, 0.81-0.87) and 89% (95% CI, 0.86-0.91) for the QFT-IT and T-Spot.TB, respectively, when restricted to performance in developed countries. In contrast, specificity of the QFT-IT was 99% (95% CI, 0.98-1.00) vs 86% for the T-Spot.TB (95% CI, 0.81-0.90). The pooled rate of indeterminate results was low, 2.1% (95% CI, 0.02-0.023) for the QFT-IT and 3.8% (95% CI, 0.035-0.042) for the T-Spot.TB, increasing to 4.4% (95% CI, 0.039-0.05) and 6.1% (95% CI, 0.052-0.071), respectively, among immunosuppressed hosts. The newest commercial IGRAs are superior, in comparison with the TST, for detecting confirmed active TB disease, especially when performed in developed countries.
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Affiliation(s)
- Roland Diel
- Department of Pulmonary Medicine, Hannover Medical School (MHH), Carl-Neuberg-Strasse 1, 30625 Hannover, Germany.
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Interferon-Gamma Release Assay in the Ascites: Early Hint for Diagnosis of Abdominal Tuberculosis. Infection 2009; 38:69-72. [DOI: 10.1007/s15010-009-9469-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2008] [Accepted: 06/09/2009] [Indexed: 10/20/2022]
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50
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Differential cytokine/chemokines and KL-6 profiles in patients with different forms of tuberculosis. Cytokine 2009; 47:132-6. [DOI: 10.1016/j.cyto.2009.05.016] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Revised: 05/22/2009] [Accepted: 05/30/2009] [Indexed: 11/22/2022]
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