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Putera I, Ten Berge JCEM, Thiadens AAHJ, Dik WA, Agrawal R, van Hagen PM, La Distia Nora R, Rombach SM. Relapse in ocular tuberculosis: relapse rate, risk factors and clinical management in a non-endemic country. Br J Ophthalmol 2024:bjo-2024-325207. [PMID: 38609164 DOI: 10.1136/bjo-2024-325207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 03/29/2024] [Indexed: 04/14/2024]
Abstract
AIMS To assess the risk of uveitis relapse in ocular tuberculosis (OTB) following clinical inactivity, to analyse clinical factors associated with relapses and to describe the management strategies for relapses. METHODS A retrospective study was conducted on a 10-year patient registry of patients with OTB diagnosed at Erasmus MC in Rotterdam, The Netherlands. Time-to-relapse of uveitis was evaluated with Kaplan-Meier curve and risk factors for relapses were analysed. RESULTS 93 OTB cases were identified, of which 75 patients achieved clinical inactivity following treatment. The median time to achieve uveitis inactivity was 3.97 months. During a median follow-up of 20.7 months (Q1-Q3: 5.2-81.2) after clinical inactivity, uveitis relapse occurred in 25 of these 75 patients (33.3%). Patients who were considered poor treatment responders for their initial uveitis episode had a significantly higher risk of relapse after achieving clinical inactivity than good responders (adjusted HR=3.84, 95% CI: 1.28 to 11.51). 13 of the 25 relapsed patients experienced multiple uveitis relapse episodes, accounting for 78 eye-relapse episodes during the entire observation period. Over half (46 out of 78, 59.0%) of these episodes were anterior uveitis. A significant number of uveitis relapse episodes (31 episodes, 39.7%) were effectively managed with topical corticosteroids. CONCLUSIONS Our results suggest that approximately one-third of patients with OTB will experience relapse after achieving clinical inactivity. The initial disease course and poor response to treatment predict the likelihood of relapse in the long-term follow-up. Topical corticosteroids were particularly effective in relapse presenting as anterior uveitis.
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Affiliation(s)
- Ikhwanuliman Putera
- Department of Ophthalmology, Faculty of Medicine, University of Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia
- Department of Ophthalmology, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Department of Internal Medicine Section Allergy and Clinical Immunology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | | | - Alberta A H J Thiadens
- Department of Ophthalmology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Willem A Dik
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Rupesh Agrawal
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK
- Lee Kong Chian School of Medicine, Nanyang Technological University of Singapore, Singapore
- Duke NUS Medical School, Singapore
| | - P Martin van Hagen
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Department of Internal Medicine Section Allergy and Clinical Immunology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Rina La Distia Nora
- Department of Ophthalmology, Faculty of Medicine, University of Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Saskia M Rombach
- Department of Internal Medicine Section Allergy and Clinical Immunology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Almutairi R. Calvarial Tuberculosis in Patient With Cervical Tuberculous Lymphadenitis: A Case Report. Cureus 2023; 15:e47055. [PMID: 38022152 PMCID: PMC10644288 DOI: 10.7759/cureus.47055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2023] [Indexed: 12/01/2023] Open
Abstract
Calvarial tuberculosis (TB) is an uncommon form of TB reported in patients with mycobacterial infections. We present a case of calvarial TB in a patient with cervical TB lymphadenitis. The patient had a history of headache and swelling of the right parietal region of the skull. CT head showed peripherally enhancing small epidural collection at the right parietal region with overlying destroyed right parietal bone. Histopathology showed giant cells, lymphocytes, and caseous necrosis. We acknowledge that cervical TB lymphadenitis poses the development of calvarial TB in our patient.
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Affiliation(s)
- Rawan Almutairi
- Infectious Disease, Infectious Disease Hospital, Andalous, KWT
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Yadav BK, Shah AK, Karunanand B, Sudan DS, Sharma M. Comparative evaluation of INF-γ as an immunological healing marker based on anti-tubercular treatment among diabetic and non-diabetic pulmonary tuberculosis patients. Horm Mol Biol Clin Investig 2022; 44:33-37. [PMID: 36148507 DOI: 10.1515/hmbci-2022-0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/20/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Tuberculosis is an infectious airborne disease caused by Mycobacterium tuberculosis. Pulmonary tuberculosis is the ninth most frequent complication of diabetes mellitus. The co-existence of TB and DM in patient causes severe TB symptoms, modify radiological findings, slower response to treatment outcomes and prognosis. IFN-γ is the key cytokine which play role in the protective immune response against mycobacterium infection. The main function of IFN-γ is macrophage activation which is able to exert its microbicidal functions. Estimation and comparison of pre and post treatment serum IFN-γ among pulmonary tuberculosis among diabetic and non-diabetic patients. METHODS The study was conducted in the Departments of Biochemistry and Pulmonary Medicine, FMHS, SGT University, Budhera, Gurugram and District TB Centre, Gurugram, Haryana, India. In this study, 100 newly diagnosed PTB patients without diabetes mellitus and 100 newly diagnosed PTB patients with diabetes mellitus (PTB-DM) above 15 years of age were included after obtaining written consent. 5 mL venous blood was collected from patients of pre and post anti-tubercular treatment. The level of IFN-γ was measured by ELISA method. RESULTS The circulating level of IFN-γ in PTB patients was significantly decreased in post-treatment (25.53 ± 6.12 pg/mL) compared to pre-treatment (58.76 ± 16.02 pg/mL) with t-value 32.03 and p-value <0.001. The circulating level of IFN-γ in PTB-DM patients was significantly decreased in post treatment (29.11 ± 7.41 pg/mL) compared to pre-treatment (44.14 ± 10.85 pg/mL) with t-value 31.35 and p-value <0.001. In the present study, level of IFN-γ in pre-treatment PTB patients (58.76 ± 16.02 pg/mL) was significantly raised compared to PTB-DM patients (44.14 ± 10.85 pg/mL) with t-value 7.55 and p-value <0.001. However, level of IFN-γ in post-treatment PTB patients (25.53 ± 6.12 pg/mL) was significantly low compared to PTB-DM patients (29.11 ± 7.41 pg/mL) with t-value 3.71 and p-value <0.001. CONCLUSIONS The decreased level of IFN-γ in post-treatment compared to pre-treatment in both PTB and PTB-DM patients had shown efficacy of anti-tubercular treatment. However, the post treatment level of IFN-γ was high in PTB-DM patients compared to PTB patients which verified that effect of ATT was low in PTB-DM.
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Affiliation(s)
- Birendra Kumar Yadav
- Department of Biochemistry, Banas Medical College & Research Institute, Palanpur, Gujarat, India
| | - Ashok Kumar Shah
- Department of Biochemistry, Adesh Medical College & Hospital, Shahbad, Haryana, India
| | - Busi Karunanand
- Department of Biochemistry, FMHS, SGT University, Gurugram, Haryana, India
| | | | - Monika Sharma
- Department of Microbiology, FMHS, SGT University, Gurugram, India
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Du Y, Xin H, Cao X, Liu Z, He Y, Zhang B, Yan J, Wang D, Guan L, Shen F, Feng B, He Y, Liu J, Jin Q, Pan S, Zhang H, Gao L. Association Between Plasma Exosomes S100A9/C4BPA and Latent Tuberculosis Infection Treatment: Proteomic Analysis Based on a Randomized Controlled Study. Front Microbiol 2022; 13:934716. [PMID: 35935235 PMCID: PMC9355536 DOI: 10.3389/fmicb.2022.934716] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 06/21/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundIdentifying host plasma exosome proteins associated with host response to latent tuberculosis infection (LTBI) treatment might promote our understanding of tuberculosis (TB) pathogenesis and provide useful tools for implementing the precise intervention.MethodsBased on an open-label randomized controlled trial (RCT) aiming to evaluate the short-course regimens for LTBI treatment, plasma exosomes from pre- and post-LTBI treatment were retrospectively detected by label-free quantitative protein mass spectrometry and validated by a parallel reaction monitoring method for participants with changed or not changed infection testing results after LTBI treatment. Eligible participants for both screening and verification sets were randomly selected from the based-RCT in a 1:1 ratio by age and gender. Reversion was defined as a decrease in IFN-γ levels from >0.70 IU/ml prior to treatment to 0.20 IU/ml within 1 week of treatment. The predictive ability of the candidate proteins was evaluated by receiver operating characteristic (ROC) analysis.ResultsTotally, two sample sets for screening (n = 40) and validation (n = 60) were included. Each of them included an equal number of subjects with persistent positive or reversed QuantiFERON-TB Gold In-Tube (QFT) results after LTBI. A total of 2,321 exosome proteins were detected and 102 differentially expressed proteins were identified to be associated with QFT reversion. Proteins with high confidence and original values intact were selected to be further verified. Totally, 9 downregulated proteins met the criteria and were validated. After verification, C4BPA and S100A9 were confirmed to be still significantly downregulated (fold change <0.67, p < 0.05). The respective areas under the ROC curve were 0.73 (95% CI: 0.57–0.89) and 0.69 (95% CI: 0.52–0.86) for C4BPA and S100A9, with a combined value of 0.78 (95% CI: 0.63–0.93). The positive and negative predictive values for combined markers were 70.10% (95% CI: 50.22–86.30%) and 55.63% (95% CI: 29.17–61.00%).ConclusionOur findings suggest that downregulated C4BPA and S100A9 in plasma exosomes might be associated with a host positive response to LTBI treatment. Further studies are warranted to verify the findings and potential underlying mechanisms in varied populations with a larger sample size.
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Affiliation(s)
- Ying Du
- National Health Commission of the People's Republic of China (NHC) Key Laboratory of Systems Biology of Pathogens, Center for Tuberculosis Research, Institute of Pathogen Biology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Henan Xin
- National Health Commission of the People's Republic of China (NHC) Key Laboratory of Systems Biology of Pathogens, Center for Tuberculosis Research, Institute of Pathogen Biology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xuefang Cao
- National Health Commission of the People's Republic of China (NHC) Key Laboratory of Systems Biology of Pathogens, Center for Tuberculosis Research, Institute of Pathogen Biology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zisen Liu
- Center for Diseases Control and Prevention of Zhongmu, Zhengzhou, China
| | - Yijun He
- National Health Commission of the People's Republic of China (NHC) Key Laboratory of Systems Biology of Pathogens, Center for Tuberculosis Research, Institute of Pathogen Biology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bin Zhang
- Center for Diseases Control and Prevention of Zhongmu, Zhengzhou, China
| | - Jiaoxia Yan
- Center for Diseases Control and Prevention of Zhongmu, Zhengzhou, China
| | - Dakuan Wang
- Center for Diseases Control and Prevention of Zhongmu, Zhengzhou, China
| | - Ling Guan
- The Sixth People's Hospital of Zhengzhou, Zhengzhou, China
| | - Fei Shen
- The Sixth People's Hospital of Zhengzhou, Zhengzhou, China
| | - Boxuan Feng
- National Health Commission of the People's Republic of China (NHC) Key Laboratory of Systems Biology of Pathogens, Center for Tuberculosis Research, Institute of Pathogen Biology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yongpeng He
- National Health Commission of the People's Republic of China (NHC) Key Laboratory of Systems Biology of Pathogens, Center for Tuberculosis Research, Institute of Pathogen Biology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jianmin Liu
- The Sixth People's Hospital of Zhengzhou, Zhengzhou, China
| | - Qi Jin
- National Health Commission of the People's Republic of China (NHC) Key Laboratory of Systems Biology of Pathogens, Center for Tuberculosis Research, Institute of Pathogen Biology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shouguo Pan
- Center for Diseases Control and Prevention of Zhongmu, Zhengzhou, China
- Shouguo Pan
| | - Haoran Zhang
- National Health Commission of the People's Republic of China (NHC) Key Laboratory of Systems Biology of Pathogens, Center for Tuberculosis Research, Institute of Pathogen Biology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Haoran Zhang
| | - Lei Gao
- National Health Commission of the People's Republic of China (NHC) Key Laboratory of Systems Biology of Pathogens, Center for Tuberculosis Research, Institute of Pathogen Biology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Lei Gao
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Abstract
Female genital tuberculosis (FGTB) is caused by Mycobacterium tuberculosis (rarely Mycobacterium bovis and/or atypical mycobacteria) being usually secondary to TB of the lungs or other organs with infection reaching through haematogenous, lymphatic route or direct spread from abdominal TB. In FGTB, fallopian tubes are affected in 90 per cent women, whereas uterine endometrium is affected in 70 per cent and ovaries in about 25 per cent women. It causes menstrual dysfunction and infertility through the damage of genital organs. Some cases may be asymptomatic. Diagnosis is often made from proper history taking, meticulous clinical examination and judicious use of investigations, especially endometrial aspirate (or biopsy) and endoscopy. Treatment is through multi-drug antitubercular treatment for adequate time period (rifampicin, isoniazid, pyrazinamide, ethambutol daily for 60 days followed by rifampicin, isoniazid, ethambutol daily for 120 days). Treatment is given for 18-24 months using the second-line drugs for drug-resistant (DR) cases. With the advent of increased access to rapid diagnostics and newer drugs, the management protocol is moving towards achieving universal drug sensitivity testing and treatment with injection-free regimens containing newer drugs, especially for new and previously treated DR cases.
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Affiliation(s)
- Jai Bhagwan Sharma
- Department of Obstetrics & Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Eshani Sharma
- Department of Obstetrics & Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Sangeeta Sharma
- Department of Paediatrics, National Institute of TB & Respiratory Diseases, New Delhi, India
| | - Sona Dharmendra
- Department of Obstetrics & Gynaecology, All India Institute of Medical Sciences, New Delhi, India
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Xin H, Zhang H, Cao X, Li X, Li M, Feng B, Jin Q, Gao L. Serum level of IL-8 is associated with reversion of QuantiFERON-TB gold in-tube tests. J Infect 2018; 78:292-298. [PMID: 30138640 DOI: 10.1016/j.jinf.2018.08.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 08/03/2018] [Accepted: 08/04/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Frequent reversion has been commonly observed in serial QuantiFERON-TB Gold In-Tube (QFT) tests, which limited its accuracy in defining the status of Mycobacterium tuberculosis (MTB) infection. Serum cytokine profiles might provide additional information to clarify the infection status. METHOD Based on a population-based cohort study aiming to track MTB infection acquisition and disease development, serum profiles of 12 cytokines were determined by bead-based multiplex assays in parallel with QFT and tuberculin skin tests (TST) to explore potential relation between serum cytokines and MTB infection status. RESULTS Totally, 309 subjects got QFT conversion in one year (2013-2014) and 46.92% (145/309) of them got reversion in 2015. The study subjects were classified into three groups according to their QFT and TST results in 2015 (QFT persistence positive, QFT-/TST + and QFT-/TST-). The serum levels of MCP-1 and IL-8 were significantly different among the three groups. Furthermore, level of IL-8 was dramatically lower in QFT-/TST- group as compared to the other two groups, and no significant difference was observed for QFT-/TST + group as comparing with persistent positive group. CONCLUSION Our results suggested that the decreased serum level of IL-8 might be potential biomarker to identify QFT reversion caused by infection clearance.
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Affiliation(s)
- Henan Xin
- MOH Key Laboratory of Systems Biology of Pathogens, Institute of Pathogen Biology, and Center for Tuberculosis, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 9 Dong Dan San Tiao, Dongcheng District, Beijing 100730, China
| | - Haoran Zhang
- MOH Key Laboratory of Systems Biology of Pathogens, Institute of Pathogen Biology, and Center for Tuberculosis, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 9 Dong Dan San Tiao, Dongcheng District, Beijing 100730, China
| | - Xuefang Cao
- MOH Key Laboratory of Systems Biology of Pathogens, Institute of Pathogen Biology, and Center for Tuberculosis, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 9 Dong Dan San Tiao, Dongcheng District, Beijing 100730, China
| | - Xiangwei Li
- MOH Key Laboratory of Systems Biology of Pathogens, Institute of Pathogen Biology, and Center for Tuberculosis, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 9 Dong Dan San Tiao, Dongcheng District, Beijing 100730, China
| | - Mufei Li
- MOH Key Laboratory of Systems Biology of Pathogens, Institute of Pathogen Biology, and Center for Tuberculosis, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 9 Dong Dan San Tiao, Dongcheng District, Beijing 100730, China
| | - Boxuan Feng
- MOH Key Laboratory of Systems Biology of Pathogens, Institute of Pathogen Biology, and Center for Tuberculosis, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 9 Dong Dan San Tiao, Dongcheng District, Beijing 100730, China
| | - Qi Jin
- MOH Key Laboratory of Systems Biology of Pathogens, Institute of Pathogen Biology, and Center for Tuberculosis, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 9 Dong Dan San Tiao, Dongcheng District, Beijing 100730, China
| | - Lei Gao
- MOH Key Laboratory of Systems Biology of Pathogens, Institute of Pathogen Biology, and Center for Tuberculosis, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 9 Dong Dan San Tiao, Dongcheng District, Beijing 100730, China.
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Reversion of QuantiFERON-TB Gold In-Tube test in individuals with and without prophylactic treatment for latent tuberculosis infection: A systematic review and meta-analysis. J Infect 2018; 77:276-282. [PMID: 29746953 DOI: 10.1016/j.jinf.2018.04.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 03/09/2018] [Accepted: 04/02/2018] [Indexed: 01/20/2023]
Abstract
OBJECTIVES Reversion of tuberculosis (TB) infection testing has been suggested to be associated with prophylactic treatment efficacy. However, evidences based on randomized controlled study were sparse. METHODS Studies on serial QuantiFERON-TB Gold In-Tube (QFT) test, among individuals with and without prophylactic treatment were identified in the databases of PubMed, MEDLINE and EMBASE up to 28 February 2018. The reversion rates were quantitatively summarized by means of meta-analysis using the random-effect model. RESULTS A total of 52 eligible studies were included in the meta-analysis on QFT test reversion rate among participants with (20 studies) and without (32 studies) prophylactic treatment. Summarized reversion rate was found to be 24.9% (95% confidence interval [CI]: 18.4-32.9%) and 25.3% (95% CI: 19.6-32.0%) for those completed or without treatment, respectively. When the analysis was restricted to the participants completed treatment, higher summarized rate of QFT reversion was found among those with longer course therapy (9INH vs. the other regimens), studies from Asia (vs. Europe and America), and individuals with immunosuppression disorders (vs. general populations). CONCLUSIONS Our results suggested that QFT reversion was frequently observed regardless of with or without prophylactic treatment. Serial QFT testing might be inappropriate for evaluating preventive treatment efficacy.
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Liang L, Shi R, Liu X, Yuan X, Zheng S, Zhang G, Wang W, Wang J, England K, Via LE, Cai Y, Goldfeder LC, Dodd LE, Barry CE, Chen RY. Interferon-gamma response to the treatment of active pulmonary and extra-pulmonary tuberculosis. Int J Tuberc Lung Dis 2017; 21:1145-1149. [PMID: 28911359 PMCID: PMC6310125 DOI: 10.5588/ijtld.16.0880] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Interferon-gamma (IFN-γ) release assays (IGRAs) are used to diagnose tuberculosis (TB) but not to measure treatment response. OBJECTIVE To measure IFN-γ response to active anti-tuberculosis treatment. DESIGN Patients from the Henan Provincial Chest Hospital, Henan, China, with TB symptoms and/or signs were enrolled into this prospective, observational cohort study and followed for 6 months of treatment, with blood and sputum samples collected at 0, 2, 4, 6, 8, 16 and 24 weeks. The QuantiFERON® TB-Gold assay was run on collected blood samples. Participants received a follow-up telephone call at 24 months to determine relapse status. RESULTS Of the 152 TB patients enrolled, 135 were eligible for this analysis: 118 pulmonary (PTB) and 17 extra-pulmonary TB (EPTB) patients. IFN-γ levels declined significantly over time among all patients (P = 0.002), with this decline driven by PTB patients (P = 0.001), largely during the initial 8 weeks of treatment (P = 0.019). IFN-γ levels did not change among EPTB patients over time or against baseline culture or drug resistance status. CONCLUSION After 6 months of effective anti-tuberculosis treatment, IFN-γ levels decreased significantly in PTB patients, largely over the initial 8 weeks of treatment. IFN-γ concentrations may offer some value for monitoring anti-tuberculosis treatment response among PTB patients.
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Affiliation(s)
- Lili Liang
- Henan Provincial Chest Hospital, Zhengzhou, Henan, China
| | - Ruiru Shi
- Henan Provincial Chest Hospital, Zhengzhou, Henan, China
| | - Xin Liu
- Henan Provincial Chest Hospital, Zhengzhou, Henan, China
| | - Xing Yuan
- Henan Provincial Chest Hospital, Zhengzhou, Henan, China
| | - Shulan Zheng
- Henan Provincial Chest Hospital, Zhengzhou, Henan, China
| | - Guolong Zhang
- Henan Public Health Clinical Center, Zhengzhou, Henan, China
| | - Wei Wang
- Henan Provincial Chest Hospital, Zhengzhou, Henan, China
| | - Jing Wang
- Clinical Research Directorate/Clinical Monitoring Research Program, Leidos Biomedical Research, Inc., NCI Campus at Frederick, Frederick, Maryland 21702
| | - Kathleen England
- Tuberculosis Research Section, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Laura E. Via
- Tuberculosis Research Section, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Ying Cai
- Tuberculosis Research Section, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Lisa C. Goldfeder
- Tuberculosis Research Section, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Lori E. Dodd
- Biostatistics Research Branch, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Clifton E. Barry
- Tuberculosis Research Section, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Ray Y. Chen
- Tuberculosis Research Section, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Maryland, United States of America
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Park IN, Shim TS. Qualitative and quantitative results of interferon-γ release assays for monitoring the response to anti-tuberculosis treatment. Korean J Intern Med 2017; 32:302-308. [PMID: 27951621 PMCID: PMC5339471 DOI: 10.3904/kjim.2016.199] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 07/29/2016] [Accepted: 10/20/2016] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS The usefulness of interferon-γ release assays (IGRAs) in monitoring to responses to anti-tuberculosis (TB) treatment is controversial. We compared the results of two IGRAs before and after anti-TB treatment in same patients with active TB. METHODS From a retrospective review, we selected patients with active TB who underwent repeated QuantiFERON-TB Gold (QFN-Gold, Cellestis Limited) and T-SPOT.TB (Oxford Immunotec) assays before and after anti-TB treatment with first-line drugs. Both tests were performed prior to the start of anti-TB treatment or within 1 week after the start of anti-TB treatment and after completion of treatment. RESULTS A total of 33 active TB patients were included in the study. On the QFN-Gold test, at baseline, 23 cases (70%) were early secreted antigenic target 6-kDa protein 6 (ESAT-6) or culture filtrate protein 10 (CFP-10) positive. On the T-SPOT. TB test, at baseline, 31 cases (94%) were ESAT-6 or CFP-10 positive. Most of patients remained both test-positive after anti-TB treatment. Although changes in interferon-γ release responses over time were highly variable in both tests, there was a mean decline of 27 and 24 spot-forming counts for ESAT-6 and CFP-10, respectively on the T-SPOT.TB test (p < 0.05 for all). CONCLUSIONS Although limited by the small number of patients and a short-term follow-up, there was significant decline in the quantitative result of the T-SPOT. TB test with treatment. However, both commercial IGRAs may not provide evidence regarding the cure of disease in Korea, a country where the prevalence of TB is within the intermediate range.
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Affiliation(s)
- I-Nae Park
- Department of Internal Medicine, Inje University Seoul Paik Hospital, Seoul, Korea
- Correspondence to I-Nae Park, M.D. Department of Internal Medicine, Inje University Seoul Paik Hospital, 9 Mareunnae-ro, Jung-gu, Seoul 04551, Korea Tel: +82-2-2270-0004 Fax: +82-2-2285-2286 E-mail:
| | - Tae Sun Shim
- Division of Pulmonology and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Suliman S, Geldenhuys H, Johnson JL, Hughes JE, Smit E, Murphy M, Toefy A, Lerumo L, Hopley C, Pienaar B, Chheng P, Nemes E, Hoft DF, Hanekom WA, Boom WH, Hatherill M, Scriba TJ. Bacillus Calmette-Guérin (BCG) Revaccination of Adults with Latent Mycobacterium tuberculosis Infection Induces Long-Lived BCG-Reactive NK Cell Responses. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2016; 197:1100-1110. [PMID: 27412415 PMCID: PMC4976036 DOI: 10.4049/jimmunol.1501996] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 06/07/2016] [Indexed: 01/14/2023]
Abstract
One third of the global population is estimated to be latently infected with Mycobacterium tuberculosis We performed a phase I randomized controlled trial of isoniazid preventive therapy (IPT) before revaccination with bacillus Calmette-Guérin (BCG) in healthy, tuberculin skin test-positive (≥15-mm induration), HIV-negative South African adults. We hypothesized that preclearance of latent bacilli with IPT modulates BCG immunogenicity following revaccination. Frequencies and coexpression of IFN-γ, TNF-α, IL-2, IL-17, and/or IL-22 in CD4 T cells and IFN-γ-expressing CD8 T, γδ T, CD3(+)CD56(+) NKT-like, and NK cells in response to BCG were measured using whole blood intracellular cytokine staining and flow cytometry. We analyzed 72 participants who were revaccinated with BCG after IPT (n = 33) or without prior IPT (n = 39). IPT had little effect on frequencies or cytokine coexpression patterns of M. tuberculosis- or BCG-specific responses. Revaccination transiently boosted BCG-specific Th1 cytokine-expressing CD4, CD8, and γδ T cells. Despite high frequencies of IFN-γ-expressing BCG-reactive CD3(+)CD56(+) NKT-like cells and CD3(-)CD56(dim) and CD3(-)CD56(hi) NK cells at baseline, BCG revaccination boosted these responses, which remained elevated up to 1 y after revaccination. Such BCG-reactive memory NK cells were induced by BCG vaccination in infants, whereas in vitro IFN-γ expression by NK cells upon BCG stimulation was dependent on IL-12 and IL-18. Our data suggest that isoniazid preclearance of M. tuberculosis bacilli has little effect on the magnitude, persistence, or functional attributes of lymphocyte responses boosted by BCG revaccination. Our study highlights the surprising durability of BCG-boosted memory NKT-like and NK cells expressing antimycobacterial effector molecules, which may be novel targets for tuberculosis vaccines.
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Affiliation(s)
- Sara Suliman
- South African Tuberculosis Vaccine Initiative (SATVI), Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Hennie Geldenhuys
- South African Tuberculosis Vaccine Initiative (SATVI), Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - John L. Johnson
- Tuberculosis Research Unit, Department of Medicine, Case Western Reserve University and University Hospitals Case Medical Center, Cleveland, OH, U.S.A
| | - Jane E. Hughes
- South African Tuberculosis Vaccine Initiative (SATVI), Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Erica Smit
- South African Tuberculosis Vaccine Initiative (SATVI), Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Melissa Murphy
- South African Tuberculosis Vaccine Initiative (SATVI), Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Asma Toefy
- South African Tuberculosis Vaccine Initiative (SATVI), Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Lesedi Lerumo
- South African Tuberculosis Vaccine Initiative (SATVI), Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Christiaan Hopley
- South African Tuberculosis Vaccine Initiative (SATVI), Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Bernadette Pienaar
- South African Tuberculosis Vaccine Initiative (SATVI), Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Phalkun Chheng
- Tuberculosis Research Unit, Department of Medicine, Case Western Reserve University and University Hospitals Case Medical Center, Cleveland, OH, U.S.A
| | - Elisa Nemes
- South African Tuberculosis Vaccine Initiative (SATVI), Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Daniel F. Hoft
- Division of Immunobiology, Departments of Internal Medicine and Molecular Biology, Saint Louis University Medical Center, and Center for Vaccine Development, Saint Louis, MO, USA
| | - Willem A. Hanekom
- South African Tuberculosis Vaccine Initiative (SATVI), Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - W. Henry Boom
- Tuberculosis Research Unit, Department of Medicine, Case Western Reserve University and University Hospitals Case Medical Center, Cleveland, OH, U.S.A
| | - Mark Hatherill
- South African Tuberculosis Vaccine Initiative (SATVI), Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Thomas J. Scriba
- South African Tuberculosis Vaccine Initiative (SATVI), Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa,Corresponding Author
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Interferon gamma release assays for monitoring the response to treatment for tuberculosis: A systematic review. Tuberculosis (Edinb) 2015; 95:639-650. [DOI: 10.1016/j.tube.2015.07.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 07/04/2015] [Indexed: 11/20/2022]
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Babu K, Bhat SS, Philips M, Subbakrishna DK. Review of Results of QuantiFERON TB Gold Test in Presumed Ocular Tuberculosis in a South Indian Patient Population. Ocul Immunol Inflamm 2015; 24:498-502. [DOI: 10.3109/09273948.2015.1010094] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Pullar ND, Steinum H, Bruun JN, Dyrhol-Riise AM. HIV patients with latent tuberculosis living in a low-endemic country do not develop active disease during a 2 year follow-up; a Norwegian prospective multicenter study. BMC Infect Dis 2014; 14:667. [PMID: 25515915 PMCID: PMC4273430 DOI: 10.1186/s12879-014-0667-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 11/26/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Interferon-γ release assays (IGRA) serve as immunodiagnostics of tuberculosis (TB) infection to identify individuals with latent TB infection (LTBI) eligible for preventive anti-TB therapy. In this longitudinal study of HIV-infected LTBI patients we have observed for possible progression to active TB as well as evaluated repeated IGRA testing in a TB low-endemic setting. METHODS QuantiFERON TB-Gold In-tube® assay (QFT), TB-SPOT.TB® (TSPOT) and tuberculin skin test (TST) were performed on 298 HIV-patients recruited from seven out-patient clinics in Norway. Patients with active TB, LTBI and negative IGRA were followed with repeat QFTs and clinical evaluation over a period of 24 months. RESULTS Seven HIV-patients (median CD4 count 270; IQR 50-340) were diagnosed with active TB at inclusion, all IGRA positive. Sixty-four (21%) HIV-patients (median CD4 count 471; IQR 342-638) were diagnosed with LTBI and of these 39 (61%) received TB preventive treatment. Neither treated nor untreated HIV-infected LTBI patients developed active TB during the 24 months. At baseline, the median interferon-γ (INF-γ) level measured by QFT was 3.48 IU/ml (IQR 0.94-8.91 IU/ml) for treated LTBI compared to 1.13 IU/ml (IQR 0.47-4.25 IU/ml) for untreated LTBI patients (p = 0.029). The QFT reversion rates were 75% for active TB, 23% for treated LTBI and 44% for untreated LTBI, whereas the conversion rate for the non-TB group was 7% despite no new TB exposure. There was no significant difference in the trend of INF-γ levels over time between treated and untreated LTBI patients. CONCLUSION The prevalence of LTBI is high among HIV-patients, but the risk of developing active TB seems to be low in patients with high CD4 counts in this TB low-endemic setting. In several patients, especially with baseline IFN-γ levels close to cut-offs, the QFT tests reverted to negative independent of preventive anti-TB treatment indicating possibly false positive tests. This highlights the importance of defining reliable cut-offs for immunodiagnostic tests and deferring preventive therapy in selected patients. Randomized studies with longer follow-up time are needed to identify HIV-patients that would benefit from LTBI treatment in a TB low-endemic setting.
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Affiliation(s)
- Nadine Durema Pullar
- Department of Internal Medicine, Section for Infectious Diseases, University Hospital of Northern Norway, N-9038, Tromsø, Norway. .,Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, N-9037, Tromsø, Norway.
| | - Harald Steinum
- Department of Infectious Diseases, Trondheim University Hospital, N-7004, Trondheim, Norway.
| | - Johan Nikolai Bruun
- Department of Internal Medicine, Section for Infectious Diseases, University Hospital of Northern Norway, N-9038, Tromsø, Norway. .,Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, N-9037, Tromsø, Norway.
| | - Anne Ma Dyrhol-Riise
- Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, N-5021, Bergen, Norway. .,Present address: Department of Infectious Diseases, Oslo University Hospital (Ullevål), pb 4956 Nydalen, 0424, Oslo, Norway. .,Institute of Clinical Medicine, University of Oslo, 0316, Oslo, Norway.
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Belay M, Legesse M, Dagne D, Mihret A, Bekele Y, Medhin G, Bjune G, Abebe F. QuantiFERON-TB Gold In-Tube test conversions and reversions among tuberculosis patients and their household contacts in Addis Ababa: a one year follow-up study. BMC Infect Dis 2014; 14:654. [PMID: 25466365 PMCID: PMC4264256 DOI: 10.1186/s12879-014-0654-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 10/29/2014] [Indexed: 11/26/2022] Open
Abstract
Background QuantiFERON-TB Gold In-Tube® (QFT-GIT) test is used for the diagnosis of latent tuberculosis (TB) infection. Besides, QFT-GIT test could allow tracking changes in immune response among TB patients and their contacts. In high TB burden settings, reports on QFT-GIT conversions and reversions among TB patients and their contacts are limited. As part of a major project to study immune responses to TB infection, we investigated QFT-GIT test conversions and reversions among smear positive pulmonary TB patients and their household contacts over 12 months. Methods We followed a total of 107 HIV negative participants (33 patients and 74 contacts) in Addis Ababa. We did QFT-GIT test at baseline and 12 months later according to the manufacturer’s instructions. Results At baseline, 25/33 (75.8%) of the patients and 50/74 (67.6%) of the contacts were QFT-GIT positive. At 12 months, 2 more patients (1 test negative and 1 indeterminate) became test positive. Besides, 11/24 (45.8%) test negative contacts became positive. Only one patient and one contact who were test positive at baseline became test negative 12 months later. At 12 months, the proportions of QFT-GIT test positives for patients and contacts were, therefore, 78.8% and 81.1%, respectively. Among contacts, the proportion of QFT-GIT test positives at 12 months was significantly higher compared to the corresponding proportion at baseline (McNemar, p = 0.006); similarly, the median IFN-γ response significantly increased at 12 months compared with the baseline level (Wilcoxon matched-pairs signed rank test, p = 0.01). Patients, however, had comparable median IFN-γ levels at baseline and 12 months later (p = 0.56). Conclusion Nearly half of QFT-GIT negative household contacts at baseline became positive at 12 months. This suggests that repeated screening of QFT-GIT negative contacts may be needed for epidemiological studies and interventions of latent TB in an endemic setting. A large longitudinal study may be needed to confirm our observations. Electronic supplementary material The online version of this article (doi:10.1186/s12879-014-0654-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mulugeta Belay
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, P.O. Box 1176, Addis Ababa, Ethiopia. .,Department of Community Medicine, Institute of Health and Society, University of Oslo, P.O. Box 1130, Blindern, 0318, Oslo, Norway.
| | - Mengistu Legesse
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, P.O. Box 1176, Addis Ababa, Ethiopia.
| | - Daniel Dagne
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, P.O. Box 1176, Addis Ababa, Ethiopia. .,Dessie Regional Health Research Laboratory Center, Amhara Regional Health Bureau, P.O. Box 686, Dessie, Ethiopia.
| | - Adane Mihret
- Armauer Hansen Research Institute, Addis Ababa, P.O. Box 1005, Ethiopia.
| | - Yonas Bekele
- Armauer Hansen Research Institute, Addis Ababa, P.O. Box 1005, Ethiopia.
| | - Girmay Medhin
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, P.O. Box 1176, Addis Ababa, Ethiopia.
| | - Gunnar Bjune
- Department of Community Medicine, Institute of Health and Society, University of Oslo, P.O. Box 1130, Blindern, 0318, Oslo, Norway.
| | - Fekadu Abebe
- Department of Community Medicine, Institute of Health and Society, University of Oslo, P.O. Box 1130, Blindern, 0318, Oslo, Norway.
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Hang NTL, Matsushita I, Shimbo T, Hong LT, Tam DB, Lien LT, Thuong PH, Cuong VC, Hijikata M, Kobayashi N, Sakurada S, Higuchi K, Harada N, Endo H, Keicho N. Association between tuberculosis recurrence and interferon-γ response during treatment. J Infect 2014; 69:616-26. [DOI: 10.1016/j.jinf.2014.06.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 06/01/2014] [Accepted: 06/16/2014] [Indexed: 01/14/2023]
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Park KH, Lee MS, Lee SO, Choi SH, Kim YS, Woo JH, Kang JK, Lee SA, Kim SH. Kinetics of T-cell-based assays on cerebrospinal fluid and peripheral blood mononuclear cells in patients with tuberculous meningitis. Korean J Intern Med 2014; 29:793-9. [PMID: 25378978 PMCID: PMC4219969 DOI: 10.3904/kjim.2014.29.6.793] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 12/03/2013] [Accepted: 12/19/2013] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND/AIMS The goal of this study was to monitor tuberculosis (TB)-specific T-cell responses in cerebrospinal fluid-mononuclear cells (CSF-MCs) and peripheral blood mononuclear cells (PBMCs) in patients with tuberculous meningitis (TBM) over the course of anti-TB therapy. METHODS Adult patients (≥ 16 years) with TBM admitted to Asan Medical Center, Seoul, South Korea, were prospectively enrolled between April 2008 and April 2011. Serial blood or CSF samples were collected over the course of the anti-TB therapy, and analyzed using an enzyme-linked immunosorbent spot (ELISPOT) assay. RESULTS Serial ELISPOT assays were performed on PBMCs from 17 patients (seven definite, four probable, and six possible TBM) and CSF-MC from nine patients (all definite TBM). The median number of interferon-gamma (IFN-γ)-producing T-cells steadily increased during the first 6 months after commencement of anti-TB therapy in PBMCs. Serial CSF-MC ELISPOT assays revealed significant variability in immune responses during the first 6 weeks of anti-TB therapy, though early increases in CSF-MC ELISPOT results were associated with treatment failure or paradoxical response. CONCLUSIONS Serial analysis of PBMCs by ELISPOT during the course of treatment was ineffective for predicting clinical response. However, increases in TB-specific IFN-γ-producing T-cells in CSF-MC during the early phase of anti-TB therapy may be predictive of clinical failure.
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Affiliation(s)
- Ki-Ho Park
- Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Mi Suk Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Ho Choi
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yang Soo Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun Hee Woo
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joong Koo Kang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Ahm Lee
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Quantiferon-TB Gold: performance for ruling out active tuberculosis in HIV-infected adults with high CD4 count in Côte d'Ivoire, West Africa. PLoS One 2014; 9:e107245. [PMID: 25330161 PMCID: PMC4199568 DOI: 10.1371/journal.pone.0107245] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 08/06/2014] [Indexed: 02/07/2023] Open
Abstract
Objective To assess the performance of QuantiFERON-TB Gold In-Tube (QFT-GIT) test for active tuberculosis (TB) in HIV adults, and its variation over time in patients on antiretroviral therapy (ART) and/or isoniazide preventive therapy (IPT). Methods Transversal study and cohort nested in the Temprano ANRS 12136 randomized controlled trial assessing benefits of initiating ART earlier than currently recommended by World Health Organization, with or without a 6-month IPT. Performance of QFT-GIT for detecting active TB at baseline in the first 50% participants, and 12-month incidence of conversion/reversion in the first 25% participants were assessed. QFT-GIT threshold for positivity was 0.35 IU/ml. Results Among the 975 first participants (median baseline CD4 count 383/mm3, positive QFT-GIT test 35%), 2.7% had active TB at baseline. QFT-GIT sensitivity, specificity, positive and negative predictive value for active TB were 88.0%, 66.6%, 6.5% and 99.5%. For the 444 patients with a second test at 12 months, rates for conversion and reversion were 9.3% and 14%. Reversion was more frequent in patients without ART and younger patients. IPT and early ART were not associated with reversion/conversion. Conclusion A negative QFT-GIT could rule out active TB in HIV-infected adults not severely immunosuppressed, thus avoiding repeated TB testing and accelerating diagnosis and care for other diseases. Trial Registration ClinicalTrials.gov NCT00495651.
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Seo KW, Ahn JJ, Ra SW, Kwon WJ, Jegal Y. Persistently retained interferon-gamma responsiveness in individuals with a history of pulmonary tuberculosis. TOHOKU J EXP MED 2014; 233:123-8. [PMID: 24881649 DOI: 10.1620/tjem.233.123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The interferon gamma (IFN-γ) release assays (IGRAs) are the best method of detecting Mycobacterium tuberculosis infection. However, reports on IGRAs results obtained during and right after the treatment of tuberculosis (TB) have presented differing results. Some studies have shown declining responses, whereas other reports described persistent, fluctuating, or increasing responses. We postulated that the IGRA-positivity will decrease or revert long time after treatment of TB, and thus, evaluated the response of IGRA in subjects with a history of pulmonary TB. Seventy subjects (M:F = 51:19; age = 53.2 ± 11.8 years) underwent tuberculin skin tests (TSTs) and IGRA. The interval of time elapsed after the completion of anti-TB treatment was < 10 years for 16 subjects, 10-20 years for 13 subjects, 20-30 years for 16 subjects, and ≥ 30 years for 25 subjects. The TST was positive in 49 subjects (74%) and negative in 17 subjects (26%). The IGRA was positive in 52 subjects (74%) and negative in 18 subjects (26%). The IFN-γ level and the size of induration showed good correlation (r = 0.525, P < 0.001). However, the correlation between time elapsed after the completion of anti-TB treatment and the size of induration or that between time and the IFN-γ level was not significant. The TST and IGRA were positive in 72.7% and 68.0% of subjects ≥ 30 years after the treatment of pulmonary TB. In conclusion, majority of subjects with a history of pulmonary TB are IGRA-positive, even a few decades after the completion of anti-TB treatment.
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Affiliation(s)
- Kwang Won Seo
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan, College of Medicine
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Johnson JL, Geldenhuys H, Thiel BA, Toefy A, Suliman S, Pienaar B, Chheng P, Scriba T, Boom WH, Hanekom W, Hatherill M. Effect of isoniazid therapy for latent TB infection on QuantiFERON-TB gold in-tube responses in adults with positive tuberculin skin test results in a high TB incidence area: a controlled study. Chest 2014; 145:612-7. [PMID: 24135768 DOI: 10.1378/chest.13-1232] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND T-cell interferon-γ release assays (IGRAs) are used in the diagnosis of Mycobacterium tuberculosis infection and could be useful biomarkers of response to treatment of latent TB infection for clinical trials, infection control units, and TB programs. METHODS This investigation was a prospective, controlled substudy of IGRA responses in 82 healthy South African adults with HIV seronegative and positive tuberculin skin test results randomly assigned to treatment with 6 months of daily isoniazid preventive therapy (IPT) or observation before Bacillus Calmette-Guérin revaccination in a clinical trial. QuantiFERON-TB Gold In-Tube (QFT-GIT) assay was used to measure interferon-γ (IFN-γ) response to mycobacterial antigens at baseline and after IPT or observation. RESULTS IFN-γ levels declined between baseline and the end of IPT (signed rank test P≤.0001) and between baseline and a similar period of observation without IPT (signed rank test P=.03). The rate of decrease in IFN-γ responses over time did not differ between the groups (Mann-Whitney-Wilcoxon test P=.31). QFT-GIT test results in two subjects (5%) in the IPT group and two subjects (5%) in the observation group reverted from positive to negative during follow-up. No significant difference was found between the groups with respect to baseline positivity or the proportion of patients whose tests reverted to negative. CONCLUSIONS IPT had no effect on changes in QFT-GIT readouts during short-term follow-up of adults with positive tuberculin skin tests in a high TB incidence setting. QFT-GIT is unlikely to be a useful biomarker of response to treatment of latent TB infection. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01119521; URL: www.clinicaltrials.gov.
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La Distia Nora R, van Velthoven ME, ten Dam-van Loon NH, Misotten T, Bakker M, van Hagen MP, Rothova A. Clinical manifestations of patients with intraocular inflammation and positive QuantiFERON-TB gold in-tube test in a country nonendemic for tuberculosis. Am J Ophthalmol 2014; 157:754-61. [PMID: 24262781 DOI: 10.1016/j.ajo.2013.11.013] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 11/12/2013] [Accepted: 11/12/2013] [Indexed: 11/27/2022]
Abstract
PURPOSE To evaluate clinical manifestations of patients with uveitis and scleritis of unknown origin and positive QuantiFERON-TB Gold In-Tube test (quantiferon) in a country not endemic for tuberculosis. DESIGN Multicenter retrospective cohort study. METHODS Retrospective review of the clinical, laboratory, and imaging data of 77 patients. Main outcome measures consisted of ocular and systemic features as well as results of laboratory examinations. RESULTS Out of all, 60 of 71 (85%) were living for at least 6 months in tuberculosis-endemic regions. Location of uveitis was variable; posterior uveitis (29/77; 38%) was the most frequent. Two clinical entities were commonly noted: retinal occlusive vasculitis (21/77; 27%) and serpiginoid choroiditis (11/77; 14%). Antituberculosis treatment was completed in 32 patients; 29 of them (91%) achieved complete remission. Mean quantiferon level was 7.5 U/mL; 71% had values above 2 U/mL and 41% above 10 U/mL. We observed no associations between quantiferon levels and clinical and/or imaging features. Previous tuberculosis infection was diagnosed in 5 of 77 patients (6.5%), while hilar/mediastinal lymphadenopathy was found in 25 of 76 patients (33%). Of these, 12 were consistent with the diagnosis of sarcoidosis, 9 were typical for (prior) tuberculosis, and 4 were compatible with both diagnoses. CONCLUSIONS Ocular features of patients with idiopathic uveitis and positive quantiferon were diverse, but retinal occlusive vasculitis and serpiginoid choroiditis were common. The quantiferon levels were usually highly elevated and 33% of patients exhibited lymphadenopathy, suggesting frequently the diagnosis of sarcoidosis. Ocular inflammation reacted favorably to antituberculosis treatment, although only a small minority had documented (prior) tuberculosis.
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Adewole OO, Ota MO, Erhabor GE, Owiafe P, Oladimeji A, Obaseki D. Interferon-gamma treatment kinetics among patients with active pulmonary tuberculosis. Niger Med J 2014; 54:376-81. [PMID: 24665150 PMCID: PMC3948958 DOI: 10.4103/0300-1652.126287] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction: Interferon-γ (IFN-γ) is essential for defence against Mycobacterium tuberculosis; however, levels in patients with active tuberculosis (TB) and changes during treatment have not been documented in our tuberculosis patients in Nigeria, hence this study has been carried out. Objective: To determine variations, treatment kinetics, and predictive value of IFN-γ levels during treatment of active tuberculosis. Design: Patients with pulmonary tuberculosis were recruited and subsequently followed up for 3 months during treatment with anti-TB. Peripheral blood was collected for IFN-γ assays, C-reactive protein and others followed by a Mantoux test. IFN-γ levels produced by stimulation with TB antigens were determined by ELISA and repeated measurement of IFN-γ were done at 1 and 3 months of anti-TB therapy. Chi Associations and correlations between IFN-γ were determined. Regression analysis was done to determine association between serial IFN-γ and treatment outcome. Results: We recruited 47 patients with active tuberculosis with a mean age of 34.8 ± 3.6 years and M:F ratio of 1.12:1. Six (11%) were HIV positive. The mean level of IFN-γ induced by TB antigens was 629 ± 114.1 pg/ml, higher for HIV-negative PTB patients compared with HIV-positive PTB patients, 609.78 ± 723.9 pg/ml and 87.88 ± 130.0 pg/ml, respectively, P-value = 0.000. The mean level of IFN-γ induced by TB antigen increased significantly from 629 ± 114.1 pg/ml to 1023.46 + 222.8 pg/ml, P-value = 0.03 and reduced to 272.3 ± 87.7 pg/ml by the third month on anti-TB drugs, P-value = 0.001. Negative correlation was observed between the mean of baseline and chest X-ray involvement, P = 0.03. There was no significant correlation between sputum smear grade with baseline and follow-up IFN-γ levels. Three-month IFN-γ level among cured patients were higher than those with treatment failure, regression analysis showed that it does not predict outcome. Conclusion: IFN-γ may be useful in early detection and monitoring response; however, large scale studies are needed.
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Affiliation(s)
- Olanisun Olufemi Adewole
- Department of Medicine, Obafemi Awolowo University and Teaching Hospitals, Ile Ife, Osun State, Nigeria
| | - Martin O Ota
- Tuberculosis Immunology Unit, Medical Research Council Unit, Banjul, Gambia
| | - Greg E Erhabor
- Department of Medicine, Obafemi Awolowo University and Teaching Hospitals, Ile Ife, Osun State, Nigeria
| | - Patrick Owiafe
- Tuberculosis Immunology Unit, Medical Research Council Unit, Banjul, Gambia
| | - Aliu Oladimeji
- Department of Medicine, Obafemi Awolowo University and Teaching Hospitals, Ile Ife, Osun State, Nigeria
| | - Daniel Obaseki
- Department of Medicine, Obafemi Awolowo University and Teaching Hospitals, Ile Ife, Osun State, Nigeria
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Efficacy of IP-10 as a biomarker for monitoring tuberculosis treatment. J Infect 2014; 68:252-8. [DOI: 10.1016/j.jinf.2013.09.033] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 08/21/2013] [Accepted: 09/09/2013] [Indexed: 02/07/2023]
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Jakob E, Max R, Zimmermann S, Dalpke AH, Alle W, Becker M, Mackensen F. Three Years of Experience with QuantiFERON-TB Gold Testing in Patients with Uveitis. Ocul Immunol Inflamm 2014; 22:478-84. [DOI: 10.3109/09273948.2013.866255] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Woo KS, Choi JL, Kim BR, Kim JE, Kim BG, Lee H, Kim KH. Significance of interferon-gamma response to mitogen in serial QuantiFERON-TB Gold In-Tube assay of routine laboratory practice. Clin Chim Acta 2014; 430:79-83. [PMID: 24389051 DOI: 10.1016/j.cca.2013.12.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 11/29/2013] [Accepted: 12/23/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Clinical data of serial interferon-γ release assay (IGRA) testing in routine laboratory practice are limited. IFN-γ response to mitogen is used as a positive control in IGRA. We assessed the association between IFN-γ response to nil, mitogen, tuberculosis (TB) mycobacterial antigens, and the variations from the results of the serial testing. METHOD A total of 299 patients with serial QuantiFERON-TB Gold In-Tube (QFT-GIT) were enrolled. The medical records of patients were reviewed for demographic information, status of Mycobacterium tuberculosis infection, treatment of tuberculosis, and the quantitative response to nil, mitogen, and TB antigen. RESULTS The initial QFT-GIT result was positive in 142 patients (47.5%), negative in 139 (46.5%), and indeterminate in 18 (6.0%). Of total, 79.6% showed concordant results in serial testing. The discordance in serial tests was significantly high in patients with a low mitogen response (≤ 3.93 IU/ml) (p<0.0001). Quantitative TB responses around the cut-off point in serial QFT-GIT were associated with an increased conversion and reversion rates (p = 0.01, p = 0.0005), respectively. CONCLUSION Because IGRAs are dynamic assays, integrated interpretation of quantitative TB response with mitogen and nil response would be helpful in serial QFT-GIT. Recommendations for the interpretation of results of serial testing for active TB will be required.
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Affiliation(s)
- Kwang-Sook Woo
- Department of Laboratory Medicine, Dong-A University College of Medicine, Busan, Republic of Korea
| | - Jae-Lim Choi
- Department of Laboratory Medicine, Dong-A University College of Medicine, Busan, Republic of Korea
| | - Bo-Ram Kim
- Department of Laboratory Medicine, Dong-A University College of Medicine, Busan, Republic of Korea
| | - Ji-Eun Kim
- Department of Laboratory Medicine, Dong-A University College of Medicine, Busan, Republic of Korea
| | - Byoung-Gwon Kim
- Department of Preventive Medicine, Dong-A University College of Medicine, Busan, Republic of Korea
| | - Hyuck Lee
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Republic of Korea
| | - Kyeong-Hee Kim
- Department of Laboratory Medicine, Dong-A University College of Medicine, Busan, Republic of Korea.
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Contribution of Interferon-γ Release Assays (IGRAs) to the Diagnosis of Latent Tuberculosis Infection After Renal Transplantation. Transplantation 2013; 95:1485-90. [DOI: 10.1097/tp.0b013e3182907073] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Jackson-Sillah D, Cliff JM, Mensah GI, Dickson E, Sowah S, Tetteh JKA, Addo KK, Ottenhoff THM, Bothamley G, Dockrell HM. Recombinant ESAT-6-CFP10 Fusion Protein Induction of Th1/Th2 Cytokines and FoxP3 Expressing Treg Cells in Pulmonary TB. PLoS One 2013; 8:e68121. [PMID: 23826366 PMCID: PMC3694917 DOI: 10.1371/journal.pone.0068121] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 05/30/2013] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Early secretory antigenic target 6 (ESAT-6) and culture filtrate protein 10 (CFP-10) are Mycobacterium tuberculosis (Mtb)-specific antigens that are secreted by actively metabolising bacteria and contribute to the virulence of the bacteria. Their ability to induce Treg and Th2 responses, particularly during the first two weeks of treatment, has not been comprehensively examined to date. The purpose of this work was to characterise Th1, Th2 and Treg responses to rESAT-6-CFP10 fusion protein in TB patients before and during the intensive phase of treatment and in healthy M.bovis BCG vaccinated donors. METHODS Forty-six newly diagnosed, HIV-negative, smear-positive pulmonary TB patients and 20 healthy donors were recruited in the UK and Ghana. Their peripheral blood mononuclear cells (PBMC) were used in ex vivo ELISPOT and in vitro cultures to identify immunological parameters of interest. RESULTS The study confirmed that protective immune responses to rESAT-6-CFP10 are impaired in active TB but improved during treatment: circulating antigen-specific IL-4-producing T-cells were increased in untreated TB but declined by two weeks of treatment while the circulating antigen-specific IFN-γ producing T cells which showed a transient rise at one week of treatment, persisted at baseline levels at two months of treatment. In vitro T cell proliferation and IFN-γ production were reduced, while IL-4 and CD4(+)FoxP3(+)CD25(hi) cell expression were increased in response to rESAT-6-CFP10 fusion protein in untreated TB. These responses were reversed during early treatment of TB. CONCLUSIONS These observations support further investigations into the possible utility of these parameters as markers of active disease and favourable treatment outcomes.
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Affiliation(s)
- Dolly Jackson-Sillah
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine (LSHTM), London, United Kingdom ; Noguchi Memorial Institute for Medical Research (NMIMR), Accra, Ghana
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Radiologic Responses in Cynomolgus Macaques for Assessing Tuberculosis Chemotherapy Regimens. Antimicrob Agents Chemother 2013; 57:4237-4244. [PMID: 23796926 DOI: 10.1128/aac.00277-13] [Citation(s) in RCA: 137] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 06/13/2013] [Indexed: 01/15/2023] Open
Abstract
Trials to test new drugs currently in development against tuberculosis in humans are impractical. All animal models to prioritize new regimens are imperfect, but nonhuman primates (NHPs) infected with Mycobacterium tuberculosis develop active tuberculosis (TB) disease with a full spectrum of lesion types seen in humans. Serial 2-deoxy-2-[18F]-fluoro-d-glucose (FDG) positron emission tomography (PET) with computed tomography (CT) imaging was performed on cynomolgus macaques during infection and chemotherapy with individual agents or the four-drug combination therapy most widely used globally. The size and metabolic activity of lung granulomas varied among animals and even within a single animal during development of disease. Individual granulomas within untreated animals had highly local and independent outcomes, some progressing in size and FDG uptake, while others waned, illustrating the highly dynamic nature of active TB. At necropsy, even untreated animals were found to have a proportion of sterile lesions consistent with the dynamics of this infection. A more marked reduction in overall metabolic activity in the lungs (decreased FDG uptake) was associated with effective treatment. A reduction in the size of individual lesions correlated with a lower bacterial burden at necropsy. Isoniazid treatment was associated with a transient increase in metabolic activity in individual lesions, whereas a net reduction occurred in most lesions from rifampin-treated animals. Quadruple-drug therapy resulted in the highest decrease in FDG uptake. The findings of PET-CT imaging may provide an important early correlate of the efficacy of novel combinations of new drugs that can be directly translated to human clinical trials.
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Trajman A, Steffen RE, Menzies D. Interferon-Gamma Release Assays versus Tuberculin Skin Testing for the Diagnosis of Latent Tuberculosis Infection: An Overview of the Evidence. Pulm Med 2013; 2013:601737. [PMID: 23476763 PMCID: PMC3582085 DOI: 10.1155/2013/601737] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Accepted: 01/10/2013] [Indexed: 11/18/2022] Open
Abstract
A profusion of articles have been published on the accuracy and uses of interferon-gamma releasing assays. Here we review the clinical applications, advantages, and limitations of the tuberculin skin test and interferon-gamma release assays and provide an overview of the most recent systematic reviews conducted for different indications for the use of these tests. We conclude that both tests are accurate to detect latent tuberculosis, although interferon-gamma release assays have higher specificity than tuberculin skin testing in BCG-vaccinated populations, particularly if BCG is received after infancy. However, both tests perform poorly to predict risk for progression to active tuberculosis. Interferon-gamma release assays have significant limitations in serial testing because of spontaneous variability and lack of a validated definition of conversion and reversion, making it difficult for clinicians to interpret changes in category (conversions and reversions). So far, the most important clinical evidence, that is, that isoniazid preventive therapy reduces the risk for progression to disease, has been produced only in tuberculin skin test-positive individuals.
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Affiliation(s)
- A. Trajman
- Gama Filho University, 20740-900 Rio de Janeiro, RJ, Brazil
- Montreal Chest Institute, McGill University, Montreal, QC, Canada H2X 2P4
| | - R. E. Steffen
- Federal University of Rio de Janeiro, 21941-913 Rio de Janeiro, RJ, Brazil
| | - D. Menzies
- Montreal Chest Institute, McGill University, Montreal, QC, Canada H2X 2P4
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Maas M, Michel AL, Rutten VPMG. Facts and dilemmas in diagnosis of tuberculosis in wildlife. Comp Immunol Microbiol Infect Dis 2012; 36:269-85. [PMID: 23218541 DOI: 10.1016/j.cimid.2012.10.010] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Revised: 10/29/2012] [Accepted: 10/31/2012] [Indexed: 11/16/2022]
Abstract
Mycobacterium bovis, causing bovine tuberculosis (BTB), has been recognized as a global threat at the wildlife-livestock-human interface, a clear "One Health" issue. Several wildlife species have been identified as maintenance hosts. Spillover of infection from these species to livestock or other wildlife species may have economic and conservation implications and infection of humans causes public health concerns, especially in developing countries. Most BTB management strategies rely on BTB testing, which can be performed for a range of purposes, from disease surveillance to diagnosing individual infected animals. New diagnostic assays are being developed for selected wildlife species. This review investigates the most frequent objectives and associated requirements for testing wildlife for tuberculosis at the level of individual animals as well as small and large populations. By aligning those with the available (immunological) ante mortem diagnostic assays, the practical challenges and limitations wildlife managers and researchers are currently faced with are highlighted.
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Affiliation(s)
- M Maas
- Division of Epidemiology, Department of Farm Animal Health, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 7, Utrecht, The Netherlands
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Papay P, Primas C, Eser A, Novacek G, Winkler S, Frantal S, Angelberger S, Mikulits A, Dejaco C, Kazemi-Shirazi L, Vogelsang H, Reinisch W. Retesting for latent tuberculosis in patients with inflammatory bowel disease treated with TNF-α inhibitors. Aliment Pharmacol Ther 2012; 36:858-65. [PMID: 22978645 DOI: 10.1111/apt.12037] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 05/26/2012] [Accepted: 08/17/2012] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients treated with TNF-α inhibitors (TNFi) are at high risk of reactivation of latent tuberculosis (LTB). Prospective studies on monitoring of TB reactivation and/or infection in this risk group are lacking. AIM To test the conversion and reversion rate of screening tests for latent TB serial tuberculin skin test (TST) and interferon-γ release assay (IGRA) under ongoing TNFi therapy. METHODS We retested consecutive patients with IBD receiving TNFi therapy for a minimum of 5 months for LTB using IGRA and TST. A detailed patient history and concomitant therapy were recorded for each subject. RESULTS After a median of 34.9 weeks (20.7–177.7), IGRA was retested in 184/227 patients (81.1%; Crohn's disease n = 139, ulcerative colitis n = 45) still under index TNFi. TST was available in 144/184 subjects (78.2%). The majority of patients were TNFi naïve (147/184, 79.9%). In a subgroup of patients who received isoniazid due to diagnosis of latent TB at baseline (n = 32), 6/13 patients (46.2%) with baseline positive IGRA and 3/22 patients (13.6%) with baseline positive TST reverted to negative at retesting. In patients without diagnosis of LTB at baseline no permanent IGRA conversion was observed, but there were 6/144 (4.2%) TST conversions from negative to positive. No single case of TB reactivation or infection was recorded during the observation period. CONCLUSIONS During treatment TNF-α inhibitors conversion was observed for tuberculin skin test, but not interferon-γ release assay. As compared with tuberculin skin test, interferon-γ release assay reverted in nearly half of isoniazid-treated patients for latent tuberculosis. However, the fact that patients in whom the interferon-γ release assay test result remained positive did not develop active tuberculosis during follow-up questions the utility of interferon-γ release assay as a monitoring tool during chemoprevention.
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Affiliation(s)
- P Papay
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
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Serial T-SPOT.TB and quantiFERON-TB-Gold In-Tube assays to monitor response to antitubercular treatment in Italian children with active or latent tuberculosis infection. Pediatr Infect Dis J 2012; 31:974-7. [PMID: 22572749 DOI: 10.1097/inf.0b013e31825d0d67] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We performed a prospective study to investigate T-SPOT.TB and QuantiFERON-TB Gold In-Tube (QFT-G-IT) dynamics during antitubercular treatment in active tuberculosis (TB) or latent TB. Eighteen children with latent TB and 26 with TB were enrolled. At 6 months of follow-up reversion rate was 5.88% (95% CI:0-13.79) for QFT-G-IT; 9.09% (95% CI:0.59-17.58) for T-SPOT.TB (P=0.921) in TB cases. Significant decline in quantitative response was observed exclusively in TB cases. Our results suggest that serial IGRA have limited use in children receiving antitubercular treatment.
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Jeong YJ, Yoon S, Koo HK, Lim HJ, Lee JS, Lee SM, Yang SC, Yoo CG, Kim YW, Han SK, Yim JJ. Positive tuberculin skin test or interferon-gamma release assay in patients with radiographic lesion suggesting old healed tuberculosis. J Korean Med Sci 2012; 27:761-6. [PMID: 22787371 PMCID: PMC3390724 DOI: 10.3346/jkms.2012.27.7.761] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Accepted: 04/03/2012] [Indexed: 11/25/2022] Open
Abstract
Radiographic lesions suggesting old healed tuberculosis (TB) is considered a risk factor for the subsequent development of active TB. The aim of this study was to estimate the positive rates of tuberculin skin test (TST) and interferon-gamma release assay (IGRA) in persons with old healed TB. Participants with lesions suggesting old healed TB on chest images and controls without such lesions were prospectively enrolled between January 1, 2010, and January 31, 2011. TST and the QuantiFERON-TB Gold In-Tube test (QFT-GIT) were performed. In total, 193 participants with old healed TB and 126 controls were recruited. The rates of positive TST and QFT-GIT among patients with old healed TB were 54.6% and 77.7%, respectively. The rates of positive TST and QFT-GIT among patients without old healed TB were 38.9% and 61.9%. Sixteen percent of participants with old healed TB showed negative results by both TST and QFT-GIT. The positive rate of TST waned among participants with old healed TB who were older than 60 yr, whereas QFT-GIT positivity was unaffected by age. The positive rates of TST and IGRA among participants with radiographic lesions suggesting old healed TB was higher than without those lesions. In addition, IGRA may be more accurate than TST for the detection of latent TB infection, especially in populations of individuals older than 60 yr.
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Affiliation(s)
- Yun-Jeong Jeong
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Soonho Yoon
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Hyeon-kyoung Koo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hyo-Jeong Lim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Sun Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Sang-Min Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Seok-Chul Yang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Chul-Gyu Yoo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Young-Whan Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Sung-Koo Han
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jae-Joon Yim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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Theron G, Peter J, Lenders L, van Zyl-Smit R, Meldau R, Govender U, Dheda K. Correlation of mycobacterium tuberculosis specific and non-specific quantitative Th1 T-cell responses with bacillary load in a high burden setting. PLoS One 2012; 7:e37436. [PMID: 22629395 PMCID: PMC3358317 DOI: 10.1371/journal.pone.0037436] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 04/23/2012] [Indexed: 12/21/2022] Open
Abstract
Background Measures of bacillary load in patients with tuberculosis (TB) may be useful for predicting and monitoring response to treatment. The relationship between quantitative T-cell responses and mycobacterial load remains unclear. We hypothesised that, in a HIV-prevalent high burden setting, the magnitude of mycobacterial antigen-specific and non-specific T-cell IFN-γ responses would correlate with (a) bacterial load and (b) culture conversion in patients undergoing treatment. Methods We compared baseline (n = 147), 2 (n = 35) and 6 month (n = 13) purified-protein-derivative (PPD) and RD1-specific (TSPOT.TB and QFT-GIT) blood RD1-specific (TSPOT.TB; QFT-GIT) responses with associates of sputum bacillary load in patients with culture-confirmed TB in Cape Town, South Africa. Results IFN-γ responses were not associated with liquid culture time-to-positivity, smear-grade, Xpert MTB/RIF-generated cycle threshold values or the presence of cavities on the chest radiograph in patients with culture-confirmed TB and irrespective of HIV-status. 2-month IGRA conversion rates (positive-to-negative) were negligible [<11% for TSPOT.TB (3/28) and QFT-GIT (1/29)] and lower compared to culture [60% (21/35); p<0.01]. Conclusions In a high burden HIV-prevalent setting T-cell IFN-γ responses to M. tuberculosis-specific and non-specific antigens do not correlate with bacillary load, including Xpert MTB/RIF-generated CT values, and are therefore poorly suited for monitoring treatment and prognostication.
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Affiliation(s)
- Grant Theron
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jonny Peter
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Laura Lenders
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Richard van Zyl-Smit
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Richard Meldau
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Ureshnie Govender
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Keertan Dheda
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- * E-mail:
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Serial interferon-gamma release assays after chemoprophylaxis in a tuberculosis outbreak cohort. Infection 2012; 40:431-5. [PMID: 22585454 DOI: 10.1007/s15010-012-0265-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Accepted: 04/19/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE Interferon-gamma release assay (IGRA) results have been suggested as a surrogate marker of treatment response in latent tuberculosis infection (LTBI). However, data have not been consistent, and most previous studies focused on participants taking isoniazid prophylaxis. The aim of this study was to elucidate the changes in the IGRA results in patients who underwent chemoprophylaxis with isoniazid and rifampicin daily for 3 months. METHODS In a TB outbreak cohort, 26 asymptomatic close contacts with normal chest radiographs and positive QuantiFERON-TB Gold In-Tube assay (QFT-GIT) results were recruited. These patients were treated with isoniazid and rifampicin daily for 3 months. The QFT-GIT was repeated at 3 and 6 months following treatment initiation. RESULTS Compared with the initial QFT-GIT results (3.59 ± 3.39 IU/mL), the interferon-gamma (IFN-γ) levels had decreased significantly at 6 months (0.84 ± 1.14 IU/mL; P = 0.005), but not at 3 months (3.58 ± 3.64 IU/mL; P = 0.98). Reversions occurred in seven (26.9 %) patients at 3 months and in an additional two participants at 6 months; a total of nine participants (34.6 %) had reversions. Recent conversion was associated with reversion of the test results (odds ratio 26.3, 95 % confidence interval 3.04-226.6). CONCLUSION Chemoprophylaxis with isoniazid and rifampicin generally decreased IFN-γ levels among tuberculosis contacts. However, only a small portion of participants achieved reversion.
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Distinguishing Latent from Active Mycobacterium tuberculosis Infection Using Elispot Assays: Looking Beyond Interferon-gamma. Cells 2012; 1:89-99. [PMID: 24710416 PMCID: PMC3901089 DOI: 10.3390/cells1020089] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 04/11/2012] [Accepted: 04/17/2012] [Indexed: 12/15/2022] Open
Abstract
Mycobacterium tuberculosis (MTB) is a global heath epidemic, its threat amplified by HIV infection and the emergence of multidrug-resistant tuberculosis (MDR-TB). Interferon (IFN)-gamma release assays (IGRAs) have improved the accuracy of detection of MTB exposure in some subject groups as compared to the Tuberculin Skin Test (TST). However, as IFN-gamma is produced by both fully rested and more recently activated populations of memory T cells, it is not surprising that the measurement of this cytokine alone cannot accurately distinguish Latent TB Infected (LTBI) subjects from those with active (infectious) disease. Accurate and rapid diagnosis of infectious individuals would allow medication to be properly allocated and other actions taken to more effectively curtail MTB spread. Analysis of multi-cytokine profiles ex vivo after stimulation of PBMCs from LTBI and active MTB subjects indicate the real possibility of successfully discerning these two disease states within 24 hours of a subject’s blood draw. Due to the unparalleled sensitivity, low cost, and ease of use of Elispot assays, we propose that via a multiplex Elispot platform the accurate distinction of LTBI from active MTB-infected individuals is within reach.
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Chiappini E, Fossi F, Bonsignori F, Sollai S, Galli L, de Martino M. Utility of interferon-γ release assay results to monitor anti-tubercular treatment in adults and children. Clin Ther 2012; 34:1041-8. [PMID: 22512899 DOI: 10.1016/j.clinthera.2012.03.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 03/13/2012] [Accepted: 03/19/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Interferon-γ release assays (IGRAs), including the commercially available T-SPOT.TB, QuantiFERON-TB Gold (QFT-G), and QuantiFERON-TB Gold In-Tube (QTF-G-IT), enable detection of circulating T lymphocytes responsive to specific Mycobacterium tuberculosis antigens. Studies of the potential role of serial IGRAs for assessment of response to anti-tubercular therapy are accumulating. OBJECTIVE The objective of this systematic review was to evaluate the potential clinical utility of serial IGRAs in anti-tubercular therapy. METHODS We conducted a literature search of the Cochrane Library and MEDLINE by PubMed, from database inception through October 1, 2011, for serial IGRA results in anti-tubercular therapy, in adults and children, using commercial stardardized assays. All types of articles in the English language were included. Meta-analysis was performed to estimate the pooled percentage of reversion from a positive to a negative IGRA value at 3- to 6-month follow-up. RESULTS According to inclusion and exclusion criteria, three T-SPOT.TB-based (n = 319 patients), three QFT-G-based (n = 75 patients), and seven QFT-G-IT-based (n = 558 patients) longitudinal studies were included. The percentage of patients with reversion from a positive to a negative IGRA value ranged from 5.71% to 13.93% for T-SPOT.TB, 5.26% to 71.05% for QFT-G, and 14.28% to 41.89% for QFT-G-IT assays. Meta-analysis estimation of reversion was feasible only for the QFT-G-IT assay, at 30.54% (95% CI, 22.89-38.75). In two pediatric studies, which were QFT-G-IT based (n = 122 children), the reported reversion rates were 14.28% and 20.33%, respectively. CONCLUSIONS Because IGRAs require time and cost resources, and reversion from positive to negative IGRA values occurs in a minority of treated patients, monitoring IGRA changes over time seems to have only speculative value in adults. Data in children are poor, but are in line with results reported in adults.
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Affiliation(s)
- Elena Chiappini
- Department of Science for Woman and Child's Health, Meyer Children's Hospital, University of Florence, Italy.
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Rhodes SG, Gunn-Mooore D, Boschiroli ML, Schiller I, Esfandiari J, Greenwald R, Lyashchenko KP. Comparative study of IFNγ and antibody tests for feline tuberculosis. Vet Immunol Immunopathol 2011; 144:129-34. [DOI: 10.1016/j.vetimm.2011.07.020] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Revised: 07/22/2011] [Accepted: 07/23/2011] [Indexed: 11/16/2022]
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de Steenwinkel JEM, de Knegt GJ, ten Kate MT, Verbrugh HA, Ottenhoff THM, Bakker-Woudenberg IAJM. Dynamics of interferon-gamma release assay and cytokine profiles in blood and respiratory tract specimens from mice with tuberculosis and the effect of therapy. Eur J Clin Microbiol Infect Dis 2011; 31:1195-201. [PMID: 21983896 PMCID: PMC3346930 DOI: 10.1007/s10096-011-1428-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Accepted: 09/12/2011] [Indexed: 12/25/2022]
Abstract
There are limitations on diagnostic methods to differentiate between active and latent tuberculosis (TB), and the prediction of latent progression to TB disease is yet complex. Traditionally, tuberculosis-specific host immune response was visualized using the tuberculin skin test. Nowadays, IFN-γ release assays (IGRA) provide a more specific and sensitive tool, by which exposure to Mtb could be determined. However, the merit of IGRA aids in diagnosing active TB is yet unclear. We adapted IGRA for use in mice, and quantifying bead-based flow cytometry techniques were used to assess cytokine profiles during the course of untreated infection and to investigate the value of IGRA and cytokines as biomarkers for therapy response. High variability of IGRA results during progression of active TB infection related to various phases of infection was obtained. However, a significant decrease in IGRA results and in levels of IFN-γ, IL-17, IP-10 or MIG was observed and appeared to be associated with successful therapy. This outcome does not support the value of IGRA to accurately diagnose active TB or to monitor infection progression. However, IGRA proved to be a useful biomarker to monitor therapy success. In addition, different cytokines might serve as biomarkers.
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Affiliation(s)
- J E M de Steenwinkel
- Department of Medical Microbiology & Infectious Diseases, Erasmus MC, University Medical Centre Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands.
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Gineys R, Bodaghi B, Carcelain G, Cassoux N, Boutin LTH, Amoura Z, Lehoang P, Trad S. QuantiFERON-TB gold cut-off value: implications for the management of tuberculosis-related ocular inflammation. Am J Ophthalmol 2011; 152:433-440.e1. [PMID: 21652022 DOI: 10.1016/j.ajo.2011.02.006] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2010] [Revised: 01/31/2011] [Accepted: 02/02/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE To evaluate the accuracy of QuantiFERON-TB Gold testing in patients with presumptive tuberculosis-ocular inflammation. DESIGN Prospective nonrandomized case series and clinical laboratory investigation. METHODS Ninety-six consecutive patients presenting with ocular inflammation between January and October 2007 were tested using QuantiFERON-TB Gold. Positive patients received a 6-month anti-tuberculosis treatment. Patient follow-up ranged from 12 months to 24 months. Treatment was considered effective at the end of follow-up, in cases of no or a 2-point decrease of ocular inflammation (SUN criteria) and systemic corticosteroids stopped or tapered to 10 mg/day. RESULTS Mean age was 51 ± 17 years. Types of ocular inflammation included scleritis (n = 7), panuveitis (n = 34), and posterior (n = 15), intermediate (n = 14), and anterior uveitis (n = 15). QuantiFERON-TB Gold was positive in 42 cases (44%), negative in 51 cases (53%), and undetermined in 3 cases (3%). Among positive QuantiFERON-TB Gold patients, 25 received a full anti-tuberculosis treatment, which was effective in 15 cases (60%). Associated systemic steroids were given to 6 patients and tapered to 10 mg/day or less in all cases. Median QuantiFERON-TB Gold value was significantly higher in the group with a successful therapeutic response (7.67 IU/mL [0.46 to 33.37]) compared to the group with treatment failure (1.22 IU/mL [0.61 to 4.4]), P = .026. CONCLUSION Results of anti-tuberculosis treatment were encouraging in QuantiFERON-TB Gold-positive ocular inflammation, especially with values over 2 IU/mL in our study, suggesting that a higher cut-off value than that given by the manufacturer should be considered to better identify ocular inflammation that can benefit from full anti-tuberculosis treatment.
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Neonakis IK, Spandidos DA, Petinaki E. Female genital tuberculosis: A review. ACTA ACUST UNITED AC 2011; 43:564-72. [DOI: 10.3109/00365548.2011.568523] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Park KH, Cho OH, Ko GB, Lee Y, Park HJ, Park SY, Moon SM, Chong YP, Lee SO, Choi SH, Kim YS, Woo JH, Kim SH. Serial Testing of T-SPOT.TBAssays with Anti-Tuberculosis Therapy in Patients with Extrapulmonay Tuberculosis. Infect Chemother 2011. [DOI: 10.3947/ic.2011.43.3.245] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Ki-Ho Park
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Oh-Hyun Cho
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gwang Beum Ko
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yumi Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyun Jung Park
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - So-Youn Park
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Song Mi Moon
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Pil Chong
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Ho Choi
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yang Soo Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun Hee Woo
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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