Effect of anti-tuberculosis drugs on hematological profiles of tuberculosis patients attending at University of Gondar Hospital, Northwest Ethiopia

A modified BPaL regimen for tuberculosis treatment replaces linezolid with inhaled spectinamides

The Nix-TB clinical trial evaluated a new 6 month regimen containing three oral drugs; bedaquiline (B), pretomanid (Pa), and linezolid (L) (BPaL regimen) for the treatment of tuberculosis (TB). This regimen achieved remarkable results as almost 90% of the multidrug-resistant or extensively drug-resistant TB participants were cured but many patients also developed severe adverse events (AEs). The AEs were associated with the long-term administration of the protein synthesis inhibitor linezolid. Spectinamide 1599 is also a protein synthesis inhibitor of Mycobacterium tuberculosis with an excellent safety profile, but it lacks oral bioavailability. Here, we propose to replace L in the BPaL regimen with spectinamide (S) administered via inhalation and we demonstrate that inhaled spectinamide 1599, combined with BPa --BPaS regimen--has similar efficacy to that of the BPaL regimen while simultaneously avoiding the L-associated AEs. The BPaL and BPaS regimens were compared in the BALB/c and C3HeB/FeJ murine chronic TB efficacy models. After 4-weeks of treatment, both regimens promoted equivalent bactericidal effects in both TB murine models. However, treatment with BPaL resulted in significant weight loss and the complete blood count suggested the development of anemia. These effects were not similarly observed in mice treated with BPaS. BPaL and BPa, but not the BPaS treatment, also decreased myeloid to erythroid ratio suggesting the S in the BPaS regimen was able to recover this effect. Moreover, the BPaL also increased concentration of proinflammatory cytokines in bone marrow compared to mice receiving BPaS regimen. These combined data suggest that inhaled spectinamide 1599 combined with BPa is an effective TB regimen without L-associated AEs.

Assessment of Knowledge, Attitude, Practice, and Associated Factors of Voluntary Blood Donation in Selected Towns of Awi Zone, Injibara, Ethiopia

Background: Blood donation is the process of collecting blood from donors who are at low risk for infection and are unlikely to jeopardize their health by blood donation. It is a lifesaving practice for people who have lost ample volumes of blood as a result of accidents, obstetric and gynecological bleeding, severe anemia, and cancer. Aim: This study is aimed at assessing knowledge, attitude, practice, and associated factors toward voluntary blood donation in Chagni, Dangila, Injibara, and Jawi towns. Subject and Methods: A community-based cross-sectional study design and multistage sampling technique were employed. The data was analyzed using SPSS version 26. Both descriptive statistics and the multivariate logistic regression model were employed to determine the significance. The association between blood donation knowledge, attitude, practice, and sociodemographic variables was tested using multivariate logistic regression. Results: In Chagni, 110 (55.6%), Dangila, 162 (79.0%), Injibara, 139 (73.5%), and Jawi, 165 (64.5%), towns had adequate knowledge regarding voluntary blood donation. In Chagni, 141 (74.6%), Dangila, 170 (66.4%), Injibara, 168 (82.0%), and Jawi, 148 (74.7%), towns had an adequate attitude regarding voluntary blood donation. In Chagni, 28 (14.1%), Dangila (15.3%), Injibara (29.3%), and Jawi (12.3%), towns practiced voluntary blood donation. Respondents' sex, education level, and age were found to be significantly associated with knowledge, attitude, and practice of blood donation. Those who had a degree and above were more likely (AOR = 9.239, 5.789, 5.468, and 9.72 at 95% CI) to know about blood donation relative to those who could not read and write in Chagni, Dangila, Injibara, and Jawi, respectively. Conclusion: The majority of respondents had adequate knowledge and attitudes toward blood donation but had lower practices toward voluntary blood donation.

Correlation of tuberculosis-related anemia severity with tuberculosis-induced inflammation in children: a six-year retrospective study

BACKGROUND

Anemia is a common complication of tuberculosis (TB), and there is evidence that its prevalence is higher in patients with TB. Although TB is very important in epidemiology, careful investigation of TB-related anemia in children has not been carried out systematically. This study aimed to describe the details of anemia in children with TB and its association with clinical characteristics and the severity of inflammation.

METHODS

In this retrospective study, we explored Hb levels in 103 children with pulmonary TB (PTB) and they were divided into anemic or non-anemic groups. Logistics regression analysis was used to study the associations between anemia and demographic characteristics. Spearman correlations analysis was performed to analyse the associations between the biochemical parameters and hemoglobin levels in blood.

RESULTS

The prevalence of anemia in children with TB was 37.9% (48.7% showed microcytic hypochromic anemia, and 5.1% showed normal cell anemia). Compared with the anemia (n = 39) group, the non-anemic group (n = 64) had longer fever duration and increased respiratory rate (P < 0.05). In logistic regression analysis, anemia was associated with lower levels of Alb and higher levels of WBC, CRP, LDH, and ESR (P < 0.05). Spearman correlations analysis showed a significant negative correlation between hemoglobin (Hb) levels and inflammatory markers. After one month of antitubercular therapy (ATT), the Hb levels of 76.9% children returned to normal.

CONCLUSIONS

Anemia is common among children with TB at diagnosis. The majority of children with TB-related anemia are mild to moderate microcytic hypochromic anemia. There is a strong correlation between the severity of anemia and the inflammation induced by TB. This suggests that anemia is a biomarker of the severity of TB in clinical practice among children.

A Modified BPaL Regimen for Tuberculosis Treatment replaces Linezolid with Inhaled Spectinamides

The Nix-TB clinical trial evaluated a new 6-month regimen containing three-oral- drugs; bedaquiline (B), pretomanid (Pa) and linezolid (L) (BPaL regimen) for treatment of tuberculosis (TB). This regimen achieved remarkable results as almost 90% of the multidrug resistant (MDR) or extensively drug resistant (XDR) TB participants were cured but many patients also developed severe adverse events (AEs). The AEs were associated with the long-term administration of the protein synthesis inhibitor linezolid. Spectinamide 1599 is also a protein synthesis inhibitor of Mycobacterium tuberculosis with an excellent safety profile but which lacks oral bioavailability. Here, we propose to replace L in the BPaL regimen with spectinamide (S) administered via inhalation and we demonstrate that inhaled spectinamide 1599, combined with BPa --BPaS regimen--has similar efficacy to that of BPaL regimen while simultaneously avoiding the L-associated AEs. The BPaL and BPaS regimens were compared in the BALB/c and C3HeB/FeJ murine chronic TB efficacy models. After 4-weeks of treatment, both regimens promoted equivalent bactericidal effect in both TB murine models. However, treatment with BPaL resulted in significant weight loss and the complete blood count suggested development of anemia. These effects were not similarly observed in mice treated with BPaS. BPaL and BPa, but no the BPaS treatment, also decreased myeloid to erythroid ratio suggesting the S in the BPaS regimen was able to recover this effect. Moreover, the BPaL also increased concentration of proinflammatory cytokines in bone marrow compared to mice receiving BPaS regimen. During therapy both regimens improved the lung lesion burden, reduced neutrophil and cytotoxic T cells counts while increased the number of B and helper and regulatory T cells. These combined data suggest that inhaled spectinamide 1599 combined with BPa is an effective TB regimen that avoids L-associated AEs.

IMPORTANCE

Tuberculosis (TB) is an airborne infectious disease that spreads via aerosols containing Mycobacterium tuberculosis (Mtb), the causative agent of TB. TB can be cured by administration of 3-4 drugs for 6-9 months but there are limited treatment options for patients infected with multidrug (MDR) and extensively resistant (XDR) strains of Mtb. BPaL is a new all-oral combination of drugs consisting of Bedaquiline (B), Pretomanid (Pa) and Linezolid (L). This regimen was able to cure ∼90% of MDR and XDR TB patients in clinical trials but many patients developed severe adverse events (AEs) associated to the long-term administration of linezolid. We evaluated a new regimen in which Linezolid in the BPaL regimen was replaced with inhaled spectinamide 1599. In the current study, we demonstrate that 4-weeks of treatment with inhaled spectinamide 1599 in combination with Bedaquiline and Pretomanid has equivalent efficacy to the BPaL drug combination and avoids the L-associated-AEs.

Level function levels and oxidative stress markers in patients with multidrug-resistant tuberculosis in the Brazilian Amazon

This study aimed to correlate the values of liver markers with oxidative stress markers in patients with multidrug-resistant tuberculosis in the Brazilian Amazon. A total of 30 patients from the Tuberculosis clinic of a referral hospital were admitted to the study. Whole blood samples were collected for analysis of liver enzyme values and oxidative stress markers by spectrophotometry. The prevalence was male (60%) and the 18-29 age group was the most affected. Patients with multidrug-resistant tuberculosis presented catalase values with a median equal to 6.94 U/gHb and for glutathione, the median was equal to 14.76 µg∕ml. As for the values of liver enzymes (AST, ALT, Gamma-GT and Alkaline phosphatase) the patients had medians equal to 60.50 (U/L); 80 (U/L); 54 (U/L); and 100 (U/L) respectively (p<0.0001). The results suggest a hepatotoxic effect of the drug, which recommends further studies with a larger number of samples in order to investigate the predictors of liver damage in patients with multidrug-resistant tuberculosis.

TubIAgnosis: A machine learning-based web application for active tuberculosis diagnosis using complete blood count data

Objective

Tuberculosis remains a major global health challenge, with delayed diagnosis contributing to increased transmission and disease burden. While microbiological tests are the gold standard for confirming active tuberculosis, many cases lack microbiological evidence, necessitating additional clinical and laboratory data for diagnosis. The complete blood count (CBC), an inexpensive and widely available test, could provide a valuable tool for tuberculosis diagnosis by analyzing disturbances in blood parameters. This study aimed to develop and evaluate a machine learning (ML)-based web application, TubIAgnosis, for diagnosing active tuberculosis using CBC data.

Methods

We conducted a retrospective case-control study using data from 449 tuberculosis patients and 1200 healthy controls in Oran, Algeria, from January 2016 to April 2023. Eight ML algorithms were trained on 18 CBC parameters and demographic data. Model performance was evaluated using balanced accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiver operating characteristic curve (AUC).

Results

The best-performing model, Extreme Gradient Boosting (XGB), achieved a balanced accuracy of 83.3%, AUC of 89.4%, sensitivity of 83.3%, and specificity of 83.3% on the testing dataset. Platelet-to-lymphocyte ratio was the most influential parameter in this ML predictive model. The best performing model (XGB) was made available online as a web application called TubIAgnosis, which is available free of charge at https://yh5f0z-ghermi-mohamed.shinyapps.io/TubIAgnosis/.

Conclusions

TubIAgnosis, a ML-based web application utilizing CBC data, demonstrated promising performance for diagnosing active tuberculosis. This accessible and cost-effective tool could complement existing diagnostic methods, particularly in resource-limited settings. Prospective studies are warranted to further validate and refine this approach.

Predictors of Change in the Anemia Status Among Pulmonary Tuberculosis Patients Following Anti-tuberculosis Treatment in Puducherry, India

Background Pulmonary tuberculosis (PTB) is commonly associated with reversible peripheral blood abnormalities. The evolution of tuberculosis (TB)-associated anemia with anti-tuberculosis treatment (ATT) has not been well elucidated. This study aimed to compare the hematological profiles at the start and end of the ATT among new sputum smear-positive (NSP) PTB patients in Puducherry, India. Methods A prospective cohort study was conducted in the 10 urban primary health centers of Puducherry from 2017 to 2020. All the NSP PTB participants aged ≥18 years registered under the National Tuberculosis Elimination Program (NTEP) were contacted within two weeks of the start of the ATT. All eligible participants were enrolled, and they were followed up till the end of ATT (180 days). Hematological profiles and anthropometric measurements were compared at the start and end of the ATT. Binomial logistic regression analysis was used to assess the predictors of changes in the anemia status at the start and end of the ATT. Results Out of 176 NSP PTB participants, 145 were followed up after treatment. Initially, 63% (111/176) patients had anemia, which decreased to 44% (64/145) by the end of treatment. The risk factors for a negative change in hemoglobin levels were female gender, below poverty level, underweight, and reduced iron intake. The adjusted risk ratios (ARRs) were 1.53 (1.24-1.88), 1.18 (1.01-1.38), 1.29 (1.02-1.64), and 1.26 (1.05-1.51),respectively. Conclusion ATT may lead to the resolution of TB-associated anemia. Moreover, female gender, possession of a red ration card, being underweight, and reduced iron intake were identified as risk factors for negative changes in hemoglobin levels during treatment.

Impact of anti-tuberculosis treatment on hematological parameters in newly diagnosed tuberculosis patients at Jimma town: a longitudinal prospective study

Tuberculosis (TB) is a significant public health problem affecting one-third of the world's population. In 2021, 1.6 million people died from TB. TB is the 13th leading cause of death and the second leading cause of infectious death after coronavirus disease 2019. Most anti-TB drugs affect hematological parameters in patients.

METHODS

This longitudinal prospective study was conducted from 03 January to 30 December 2019. Patients who completed a course of TB treatment were candidates for analysis. Sputum and blood samples were collected from each study participant and analyzed by the Gene X-pert machine and a HumaCount 30 hematology analyzer (Human GmbH). SPSS version 20 and R programming software version 4.2.3 were used for data analysis. Friedman's test was used to assess statistical significance. P-values ​​less than 0.05 were considered statistically significant.

RESULTS

A total of 148 patients who completed the course of TB treatment correctly were a candidate for final analysis. Ninety-one (61.5%) study participants were male; the median age was 27.6±9.8 years. Moreover, most of the study participants (84.4%) had pulmonary TB. Most of the hematological parameters had changed in the phases of TB treatment. After anti-TB treatment, there is a significant difference in hematological parameters in red blood cell count, hemoglobin concentration, hematocrit percentage, platelet count, and white blood cell count.

CONCLUSION

Anemia and leucopenia are the most significant problems after TB treatment. Regular checking of these parameters is essential for the patient.

Standardization and validation of a novel UPLC-MS/MS method to quantify first line anti-tuberculosis drugs in plasma and dried blood spots

Tuberculosis (TB) is a high-burden infectious disease with high prevalence and mortality rates. The first-line anti-TB drugs include isoniazid (INH), rifampicin (RMP), pyrazinamide (PZA), and ethambutol (EMB). At present, the standard method of blood sampling for therapeutic drug monitoring (TDM) analysis is venipuncture. Dried blood spots (DBS) are a minimally invasive method for collecting small quantities of whole blood from fingertips. The aim of the current study was to develop an ultrahigh-performance liquid chromatography technique coupled to tandem mass spectrometry (UPLC-MS/MS) for simultaneous quantification of the first-line anti-TB drugs in human plasma and DBS as a sampling alternative. The separation and detection conditions were optimized to quantify INH, RMP, PZA, and EMB in both matrices in an ACQUITY UPLC H Class system coupled to a XEVO TQD detector. Chromatographic separation was performed through an Acquity HSS T3 column (2.1 × 100 mm, 1.8 μm) with 0.1% formic acid in water and acetonitrile as the mobile phase. The total run time was 7 min for both methods, with retention time in plasma of 0.85, 1.22, 3.16, and 4.04 min and 0.74, 0.87, 0.97, and 4.16 min for EMB, INH, PZA, and RMP in DBS, respectively. The bioanalytical methods developed were proved selective, linear, precise, and accurate (inter- and intra-assay); the matrix effect was demonstrated to be within the established limits. Short- and long-term stability, freeze-thaw cycles for plasma, and short-term stability for DBS were established. A total of 15 patients with 46 ± 17 (mean ± SD) years old were included, and anti-TB drug concentrations were quantified on plasma and DBS as proof of concept. Based on RMP and INH plasma concentrations (Cp), and Bayesian estimation of individual pharmacokinetic parameters, a dose adjustment was necessary for 93% of patients. The slopes of the correlation lines between plasma and DBS concentrations of RMP, EMB, INH, and PZA were 0.5321, 0.8125, 0.5680, and 0.6791, respectively. Finally, significant correlations (p < 0.05) were observed between DBS and plasma concentrations for RMP (r2 = 0.6961), EMB (r2 = 0.4369), INH (r2 = 0.8675) and PZA (r2 = 0.7363). A simple, fast, and reliable UPLC-MS/MS method was developed to quantify first-line anti-TB drugs in plasma and DBS, which provides an easy sampling and storage to be applied as a new strategy for TDM in patients with TB.

Oral therapy for myelodysplastic syndromes/neoplasms and acute myeloid leukemia: a revolution in progress

INTRODUCTION

Patients with myeloid neoplasms such as myelodysplastic syndromes/neoplasms (MDS) and acute myeloid leukemia (AML) are generally older, and many are not eligible for curative intent intensive therapies and/or allogeneic hematopoietic stem cell transplantation. While lower intensity, hypomethylating agent (HMA)-based therapies such as azacitidine+venetoclax have improved patient outcomes significantly, responses are not durable, and most patients die from disease-related complications. The approvals of oral HMAs such as cedazuridine-decitabine (C-DEC) and oral azacitidine (CC-486) have kindled the hope that myeloid malignancies may soon be treated with total oral therapy.

AREAS COVERED

We review all-oral therapies including the approvals of C-DEC and CC-486 in MDS and AML, respectively, in addition to emerging all-oral therapies, both monotherapy and combination, in higher-risk (HR) MDS and AML.

EXPERT OPINION

Oral HMAs have the potential to be a convenient and efficacy-equivalent treatment option for patients with HR-MDS or AML and improve their quality of life by reducing clinic visits for medication administration. Total-oral therapy combinations, largely including an oral HMA 'backbone,' are in the early phases of clinical development, and it is our hope that well-designed trials employing these agents may soon allow the identification of optimal regimens that deliver effective disease-directed therapy with good tolerability.

Partial Sheehan's syndrome with abdominal tuberculosis presented with pancytopenia and fluctuating thyroid profile: a case report

Sheehan's syndrome is a well-recognized cause of panhypopituitarism secondary to pituitary apoplexy, followed by postpartum hemorrhage. Depending upon the degree of ischemic injury, it can be either partial or complete.

Case presentation

We report an interesting case of a 35-year-old woman admitted to our hospital with complaints of abdominal distension, which was later presumed to be due to disseminated tuberculosis (TB) after excluding the possible differentials. During the treatment course, she was going through repeated attacks of hypovolemic shock and hypoglycemia due to adrenocortical insufficiency. This, along with the history of prolonged amenorrhea 4 years back due to severe postpartum hemorrhage in her last pregnancy, has led us to our diagnosis of partial Sheehan's syndrome. After 1 month of starting steroid and anti-TB therapy, it was quite surprising when she presented with features of pancytopenia and antitubercular drug-induced hepatitis.

Discussion

Sheehan's syndrome may have a varying degree of presentation depending upon the degree of damage to the pituitary gland, which includes amenorrhea, lactation failure, adrenocortical insufficiency, hyponatremia, hypoglycemia, as well as pancytopenia in some rare instances The hormone panel especially the thyroid profile should be monitored carefully. Such cases are often challenging to deal with because of their varying degrees of presentation and the delay in diagnosis due to a lack of clinical suspicion.

Conclusion

Therefore, we believe that this rare presentation of pancytopenia in Sheehan's syndrome with fluctuating thyroid profile and abdominal TB in the background will let clinicians approach such a rare disease differently.

Platelet, Neutrophil and Lymphocyte Quantitative Abnormalities in Patients with Heart Failure: A Retrospective Study

Background

Heart failure pathophysiology and its clinical symptoms are characterized by inflammation. Elevated levels of leukocyte subpopulations are a well-known indicator of inflammation and play a predictive role in determining the prognosis of patients with cardiovascular diseases. Besides, platelets are essential mediators of inflammation, especially when they interact with leukocytes. Platelet synthesis, activation, and function are all impacted by heart failure. Thus, the study was aimed at determining the magnitude of platelet, neutrophil, and lymphocyte abnormalities in patients with heart failure.

Methods

A retrospective cross-sectional study was conducted from June to July 2022 at the University of Gondar comprehensive specialized hospital. A total of 245 medical records of heart failure patients were included. Data regarding socio-demographic, clinical, and some hematological and biochemical parameters were collected from medical records. Data was entered into Epi-Data 4.6.0.2 and then exported to Stata 11.0 statistical software for analysis. A binary logistic regression analysis with its odds ratio was calculated to identify factors associated with the outcome variables. P-value <0.05 was considered statistically significant.

Results

The most frequent leukocyte abnormality among adults with heart failure was neutrophilia, which was detected in 17.55% (95% CI: 13.26-22.87). Besides, lymphocytosis was observed in 10.20% (95% CI: 6.97-14.70) of patients. The magnitude of thrombocytopenia and thrombocytosis among patients with heart failure was 12.24% (95% CI: 8.67-17.01%) and 2.86% (95% CI: 1.36-5.90%), respectively. Only being female was significantly associated with neutrophilia in patients with heart failure (AOR = 2.33; 95% CI: 1.05-5.16). However, none of the variables were significantly associated with platelet and lymphocyte abnormalities.

Conclusion

Neutrophilia, lymphocytosis, and thrombocytopenia are the common leukocyte and platelet abnormalities in heart failure patients. Therefore, early detection and management of the underlying causes of those abnormalities may be important to improve patients' outcomes and prevent further complications.

Antituberculous Drug-Induced Hepatitis in a Patient With Congenital Adrenal Hyperplasia: A Clinical Challenge

Pulmonary tuberculosis (TB) is highly prevalent in Pakistan, and immunosuppressed individuals (including those on long-term corticosteroid therapy) are at an especially high risk of infection. Owing to the limited number of effective antituberculous drugs, treating resistant cases or patients who develop unfavorable side effects from the first-line agents becomes a daunting task. We discuss a patient with congenital adrenal hyperplasia (CAH) suffering from pulmonary TB who developed drug-induced hepatitis after being started on recommended first-line anti-TB drugs.

Modeling Time to Cure of Deep Vein Thrombosis Using Cox Proportional Model in Southwest of Ethiopia

Background

Globally, there are about 10 million cases of deep vein thrombosis every year, and it is the third leading cardiovascular disease after myocardial infarction and stroke. The objective of the study is to assess risk factors of time to cure patients of deep vein thrombosis in southwest Ethiopia.

Methods

A retrospective cohort study design was used. The study population was deep vein thrombosis patients at purposively selected hospitals in Southwest Ethiopia from January 2017 to December 2020. Cox proportional hazard model was used to identify risk factors associated with deep vein thrombosis.

Results

Out of the total 1068 registered as deep vein thrombosis patients, 263(24.6%) were cured during the study period, and 805(75.4%) were censored. Results of the Cox proportional hazard model show that; age, gender, family history of deep vein thrombosis, smoking status, immobilize and alcohol consumption were factors associated with deep vein thrombosis (p-value<0.05).

Conclusion

The patients with a family history of deep vein thrombosis, prolonged immobilization, greater the 50 years, smoking cigarettes, female (non-pregnant) and alcohol users had a longer curing time of deep vein thrombosis compared to others.

Magnitudes of Risk Factors of Venous Thromboembolism and Quality of Anticoagulant Therapy in Ethiopia: A Systematic Review

Background

Venous thromboembolism is one of the major public health problems in the world. Though several studies were conducted to estimate common risk factors of venous thromboembolism and quality of anticoagulant therapy in Ethiopia, it is difficult to estimate the overall burdens of risk factors and quality of anticoagulant use because of the lack of a nationwide study.

Objective

To assess magnitudes of risk factors of venous thromboembolism and quality of anticoagulant therapy in Ethiopia.

Materials and Methods

Electronic searching using PubMed, EMBASE, Science Direct, Cochrane Database, Scopus, Hinari, Sci-Hub, African Journals Online Library, and Free-text Web Searches using Google Scholar was conducted from September, 15 to October 27, 2021. Each of the original studies was identified by Mesh terms and Boolean search technique using full title, various keywords and was assessed using the Joanna Briggs Institute Critical Appraisal Checklist. The data were extracted using a format prepared in Microsoft Excel and exported to STATA 14.0 for the outcome analyses.

Results

The database search delivered a total of 2118 studies. After articles were removed by duplications, titles, reading the abstract, and assessed for eligibility criteria, 12 articles were found suitable for the systematic review. Prolonged immobilization (41.30%) was the most commonly observed risk factor of venous thrombosis followed by acute infection (40.25%). The proportion of therapeutic range (INR = 2-3), sub-therapeutic range (INR <2), and supra-therapeutic range (INR >3) were 32.15%, 47.58%, and 17.62%, respectively. One hundred and thirty-eight patients (11.4%) have developed minor or major bleeding complications.

Conclusion

Prolonged immobilization and acute infection were the main risk factors for venous thromboembolism. The quality of anticoagulant therapy in Ethiopia was poor and bleeding complications were high. A strong effort is needed to improve the quality of anticoagulation and close monitoring of patients' international normalized ratio is required to improve treatment outcomes.

Prevalence of anaemia and associated factors among people with pulmonary tuberculosis in Uganda

Anaemia predicts delayed sputum conversion and mortality in tuberculosis (TB). We determined the prevalence and factors associated with anaemia among people with TB at the National Tuberculosis Treatment Centre in Uganda. People with bacteriologically confirmed TB were consecutively enrolled in a cross-sectional study between August 2017 and March 2018. Blood samples were tested for a full blood hemogram, HIV infection, and CD4+ and CD8+ T-cell counts. Anaemia was defined as a haemoglobin level of <13.0 grams per decilitre (g/dl) for males and <12.0 g/dl for females. Of 358 participants, 210 (58.7%, 95% confidence interval (CI) 53.4-63.8) had anaemia. Anaemia was associated with night sweats, a longer duration of fever, low body mass index (BMI), hyperthermia, high sputum bacillary loads, HIV co-infection, and low CD4 and CD8 counts at bivariate analysis. Factors associated with anaemia at multivariable analysis were low BMI (odds ratio (OR) 2.93, 95% CI 1.70-5.05, P < 0.001), low CD4:CD8 ratio (OR 2.54, 95% CI 1.07-6.04, P = 0.035) and microcytosis (OR 4.23, 95% CI 2.17-8.25, P < 0.001). Anaemia may be associated with the features of severe TB disease and should be considered in TB severity scores.

The pattern of comorbidity and its prevalence among drug-resistant tuberculosis patients at treatment initiation in Lagos, Nigeria

BACKGROUND

Multimorbidity is increasingly being recognized as a serious public health concern in the control of both drug-susceptible and drug-resistant tuberculosis (DR-TB). This study assessed the pattern of comorbidities and their prevalence in DR-TB patients at treatment initiation in Lagos, Nigeria.

METHODS

A cross-sectional study was conducted. The baseline laboratory records (human immunodeficiency virus [HIV] status, fasting blood sugar, audiometry, thyroid function tests, serum electrolyte, haemoglobin level and pregnancy test) of DR-TB patients initiated on treatment in Lagos, Nigeria between 1 August 2014 and 31 March 2017 were reviewed.

RESULTS

A total of 565 DR-TB patients' laboratory records were reviewed, of which 397 (70.3%) had comorbidities. The proportion with one, two, three and four comorbidities was 60.2%, 29.7%, 8.1% and 2.0%, respectively. Anaemia was the most common (48.1%) comorbid condition, while anaemia and hypokalaemia (7.3%), anaemia and hypothyroidism (6.5%) and anaemia and HIV (5%) were most common among patients with more than one comorbid condition. DR-TB patients with comorbidity were significantly older (34.8±12.3 y) than those without comorbidity (32.0±12.8 y) (p=0.038). Of the 176 females in the reproductive age group, 8 (4.5%) were pregnant at baseline.

CONCLUSIONS

The prevalence of comorbidity among DR-TB patients was high. There is a need for the national TB program to expand its DR-TB council of experts and also integrate reproductive health services into DR-TB management in Nigeria.

Prediction of Treatment Outcome with Inflammatory Biomarkers after 2 Months of Therapy in Pulmonary Tuberculosis Patients: Preliminary Results

Pro-inflammatory mediators play an important role in the pathogenesis of pulmonary tuberculosis. Consecutively, 26 pulmonary tuberculosis patients were enrolled in our study based on the exclusion criteria. We have used Spearman’s correlation analysis, hierarchical clustering and regression modelling to evaluate the association of 11 biomarkers with culture status after antituberculosis treatment. The results of our study demonstrated that six inflammatory biomarkers of 11, C-reactive protein (CRP), white blood cells (WBC), neutrophils, interferon gamma inducible protein 10, C-reactive protein (CRP) to albumin ratio (CAR) and neutrophil to albumin ratio (NAR), were significantly associated with culture negativity. The predictive ability of a composite model of seven biomarkers was superior to that of any single biomarker based on area under the receiver operating characteristic curve (AUC) analysis, indicating an excellent prediction efficacy (AUC:0.892; 95% CI:0.732-1.0). We also found that the highest significant trends and lower levels of CRP and IP-10 were observed in the two-month treated tuberculosis (TB) patients. We believe that our study may be valuable in providing preliminary results for an additional strategy in monitoring and management of the clinical outcome of pulmonary tuberculosis. Using a panel of predictors added a superior value in predicting culture status after anti-TB therapy.

Hematologic parameters in pulmonary tuberculosis patients based on the microscopic sputum examination

INTRODUCTION

This study aimed to analyze various hematological manifestations in tuberculosis (TB) patients using positive and negative smear sputum microscopy.

METHODS

This study was a retrospective study with cross-sectional design. The study subjects consisted of patients diagnosed with tuberculosis who were recruited consecutively at Rumah Sakit Islam Jakarta Sukapura hospital from 1st of January 2015 to 30 of June 2017.

RESULTS

There were significant differences in hematological parameters, including leucocytes, erythrocytes, thrombocytes, and erythrocyte sedimentation rates between acid-fast Bacillus positive (+) and negative (-).

CONCLUSIONS

Changes in the results from the hematological examination in pulmonary TB patients could be used as parameters for diagnosis, prognosis, and response to therapy.

Effects of co-administration of Unani pharmacopoeia formulations Qurs Tabasheer Sartani and Arq Hara Bhara with CAT-I antitubercular drugs in rats

OBJECTIVES

Tuberculosis continues to be a major public health problem globally, despite incredible advancements in healthcare system. In Unani system of medicine, Qurs Tabasheer Sarthani (QTS) and Arq Hara Bhara (AHB) have been traditionally used for tuberculosis like conditions. The study was aimed to investigate the effects of co-administration of QTS and AHB with category I first line antitubercular drugs (CAT-I) on the indices of liver and kidney function in rats.

METHODS

QTS and AHB were prepared individually and mixed to achieve final compound Unani pharmacopoeia formulation (UPF). The human equivalent doses for rats were calculated and administered with and without CAT-I. The effects of the formulations on serum indices of kidney and liver function, hematological markers and plasma CAT-I drug levels were estimated at 14th, 60th & 180th days of treatment.

RESULTS

The administration of UPF, CAT-I and UPF + CAT-I altered the levels of aspartate transaminase (AST), alanine transaminase (ALT), alkaline phosphatase (ALP) and gamma glutamyltransferase (GGT) and haematological markers. These alterations were within permissible range and randomly distributed among groups during various time points. Administration of CAT-I alone resulted in moderate histopathological changes which were completely abrogated in CAT-I + UPF co-administered animals. The co-administration of UPF with CAT-I improved the plasma peak rifampicin (RIF) levels, without altering the liver and kidney functions.

CONCLUSIONS

The co-administration of UPF with ATT improved liver and kidney functions and increased the plasma levels of RIF. These beneficial findings provide a scope to evaluate the pharmacokinetic studies in humans.

Haematological profiles after Intensive phase of Anti Koch Treatment with special emphasis on bone marrow changes

BACKGROUND

Tuberculosis remains a major public health problem in various parts of the world. It leads to various haematological changes. Study of these haematological changes will help better patient management.

OBJECTIVE & METHODS

It is to evaluate haematological changes in tuberculosis patients and compare the result with special emphasis to bone marrow changes as active case search is sharply decreasing the miliary tuberculosis. It is also to evaluate the patients with before and after the Intensive Phase of Anti Koch Treatment. Sputum positive and sputum negative tuberculosis patients confirmed by other ancillary techniques were included into this study. It is conducted at a tertiary level hospital in rural area.

RESULT

In this study bone marrow hypercellularity was of erythroid series with only 1.92% patients showed granuloma in bone marrow aspiration. In addition to bone marrow changes, significant changes were evident in haemoglobin level, Erythrocyte Sedimentation Rate (ESR) Total White Blood Cell count and RBC count.

DISCUSSION

In majority cases this study showed Erythroid Hyperplasia. It is sharp contrast with other study where myeloid hyperplasia was evident. This study also differs from other study where high number of bone marrow granuloma was reported. In this study only 1.92% cases showed bone marrow granuloma. This study also documented higher number of anaemic cases mostly because of the institute serves poor and tribal population.

CONCLUSION

In our study the cases showing granuloma and hyperplasia of myeloid series were limited. With introduction of Directly Observed Treatment and house to house active case search helped to sharply decrease bone marrow granuloma by limiting multi-organ spread. This study showed, ESR level may be considered as prognostic parameters of tuberculosis.

Evaluation of prognostic significance of hematological profiles after the intensive phase treatment in pulmonary tuberculosis patients from Romania

We evaluated in this cohort study the predictive ability of 23 peripheral blood parameters and ratios for treatment outcomes after the 2-month intensive phase in patients with PTB. In 63 patients out of 90 that turned culture negative, a significant decrease in white blood cell count, neutrophils, monocyte, hemoglobin, platelet, plateletcrit, erythrocyte sedimentation rate, MLR, NLR, PLR and SII values after anti-TB therapy compared to pretreatment was observed (p <0.001). Logistic regression analysis generated a model of predictors consisting of nine covariates. Spearman’s correlation analysis revealed significant positive correlations between NLR with NEU (r = 0.79, p<0.01), SII with NEU (r = 0.846, p<0.01), PLT with SII (r = 0.831, p<0.01), PLT with PCT (r = 0.71, p<0.01) and MPV with P-LCR (r = 0,897, p<0.01) in 63 patients out of 90 that turned culture negative after 2 months of treatment. ROC curve analysis indicated that all areas under the curve (AUC) revealed no statistically significant results, except lymphocyte for culture conversion. In summary, here we observed a set of hematological parameters that declined significantly as the disease was treated in patients that turned culture negative. Despite some limitations, our findings are useful for further studies aiming to identify hematological profiles that could predict the treatment outcome.

Isolated Nodal TBC Reactivation in a Patient with Post-Thrombocythemia Myelofibrosis Treated with Ruxolitinib: Case Report and Review of the Literature

Ruxolitinib side effects include the most frequent hematological toxicity along with a more recently evidenced immunosuppressive activity, interfering both with the innate and adaptive immunity, and several cases of reactivation of latent infections by opportunistic agents in patients in treatment with ruxolitinib have been published in the last years. Several pathophysiological mechanisms may explain an association between ruxolitinib and opportunistic infections. From what we know, the only case of an isolated lymph node TBC reactivation in a ruxolitinib-treated myelofibrosis (MF) patient was reported by Patil et al. in 2016 [Int J Med Sci Public Health. 2017;6(3):1]. Other 10 cases describing TBC reactivations in MF patients assuming ruxolitinib and successfully treated with 4-drug anti-TBC therapy are available in the literature to date. The case we reported describes an isolated lymph nodal TBC reactivation in a patient with the diagnosis of post-essential thrombocythemia-MF during ruxolitinib treatment after a long course of interferon-a (IFN-α2b) assumed for the previous diagnosis of ET. The case we report teaches that lymphadenopathy with or without constitutional symptoms developing during ruxolitinib therapy should be considered as a possible manifestation of a TBC reactivation in patients with a previous positive TBC-exposure test. In these cases, Ziel-Nielsen testing on urine and sputum has to be performed to rule out infectiousness and eventually isolate the patient. Moreover, previous long-time exposition to IFN-α2b may be related with a higher risk for TBC reactivation in these subset of patients. We encourage reevaluation of the cohorts of patients treated with ruxolitinib in previous and current large prospective studies to study the possible correlation between previous exposition to IFN-α2b and TBC reactivation.

Alcohol use disorders in multidrug resistant tuberculosis (MDR-TB) patients and their non-tuberculosis family contacts in Nigeria

Introduction

the main aim of this study was to determine the prevalence and associated factors of alcohol use disorder (AUD) in patients with Multi-Drug Treatment-Resistant Tuberculosis (MDR-TB) compared with their non-tuberculosis control, and its association with disease pattern and associated medical comorbidities.

Methods

MDR-TB patients (128) and their respective caregivers were interviewed in a treatment unit in Nigeria. Diagnosis of AUD was made using the Structured Clinical Interview for DSM-IV Axis I Disorder, information was obtained on the severity of the TB and associated health problems.

Results

prevalence of AUD was (21.9%) and was significantly higher among cases than in controls (2.3%), p = 0.006. Severe TB, OR = 3.33 (1.56-6.83), hematological diseases, OR = 2.34 (1.06-4.33) and HIV/AIDS, OR = 3.01 (1.67-7.01) were the strongest predictors of AUD at 95% CI. Conclusion: AUD was highly prevalent in MDR-TB and was associated with certain medical comorbidities and increased severity of the illness.

Alanine transaminase and hemoglobin appear to predict the occurrence of antituberculosis medication hepatotoxicity; findings and implications in Botswana

OBJECTIVE

Tuberculosis (TB) remains a global health problem, with medications having adverse effects including drug-induced hepatotoxicity. We determined the prevalence of anti-tuberculosis drug-induced hepatotoxicity and associated risk factors.

METHODS

Retrospective cross-sectional study in Botswana including TB patients admitted from 1 June 2017 to 30 June 2018. Anti-TB drug-induced hepatotoxicity was categorized according to WHO criteria whereas causality assessment was made according to the updated Roussel Uclaf Causality Assessment Method (RUCAM) scale. The association between hepatotoxicity and included variables was undertaken by binary logistic regression.

RESULTS

Out of 112 patient files, 15 (13.4%) developed hepatotoxicity after an average of 20.4 days from the start of treatment. Grade 3 and 4 hepatotoxicity was found in 66.7% of the cases. According to the updated RUCAM tool, 86.7% of patients were categorized as having possible anti-TB-associated hepatotoxicity. Patients with elevated baseline alanine transaminase (ALT) were more likely to develop hepatotoxicity (OR = 3.484, 95% CI = 1.02-11.90). Patients with normal hemoglobin (Hb ≥ 12 g/dl) were also more likely to develop hepatotoxicity (OR = 4.413, 95% CI = 1.160-14.8).

CONCLUSION

Overall, normal hemoglobin and elevated baseline ALT levels were significantly associated with anti-TB drug-induced hepatotoxicity. Additional research is needed to explore this association further.

Tuberculosis IRIS: Pathogenesis, Presentation, and Management across the Spectrum of Disease

Antiretroviral therapy (ART), while essential in combatting tuberculosis (TB) and HIV coinfection, is often complicated by the TB-associated immune reconstitution inflammatory syndrome (TB-IRIS). Depending on the TB disease site and treatment status at ART initiation, this immune-mediated worsening of TB pathology can take the form of paradoxical TB-IRIS, unmasking TB-IRIS, or CNS TB-IRIS. Each form of TB-IRIS has unique implications for diagnosis and treatment. Recently published studies have emphasized the importance of neutrophils and T cell subtypes in TB-IRIS pathogenesis, alongside the recognized role of CD4 T cells and macrophages. Research has also refined our prognostic understanding, revealing how the disease can impact lung function. While corticosteroids remain the only trial-supported therapy for prevention and management of TB-IRIS, increasing interest has been given to biologic therapies directly targeting the immune pathology. TB-IRIS, especially its unmasking form, remains incompletely described and more data is needed to validate biomarkers for diagnosis. Management strategies remain suboptimal, especially in the highly morbid central nervous system (CNS) form of the disease, and further trials are necessary to refine treatment. In this review we will summarize the current understanding of the immunopathogenesis, the presentation of TB-IRIS and the evidence for management recommendations.

Toxicoproteomic Profiling of hPXR Transgenic Mice Treated with Rifampicin and Isoniazid

Tuberculosis is a global health threat that affects millions of people every year, and treatment-limiting toxicity remains a considerable source of treatment failure. Recent reports have characterized the nature of hPXR-mediated hepatotoxicity and the systemic toxicity of antitubercular drugs. The antitubercular drug isoniazid plays a role in such pathologic states as acute intermittent porphyria, anemia, hepatotoxicity, hypercoagulable states (deep vein thrombosis, pulmonary embolism, or ischemic stroke), pellagra (vitamin B₃ deficiency), peripheral neuropathy, and vitamin B₆ deficiency. However, the mechanisms by which isoniazid administration leads to these states are unclear. To elucidate the mechanism of rifampicin- and isoniazid-induced liver and systemic injury, we performed tandem mass tag mass spectrometry-based proteomic screening of mPxr^-/- and hPXR mice treated with combinations of rifampicin and isoniazid. Proteomic profiling analysis suggested that the hPXR liver proteome is affected by antitubercular therapy to disrupt [Fe-S] cluster assembly machinery, [2Fe-2S] cluster-containing proteins, cytochrome P450 enzymes, heme biosynthesis, homocysteine catabolism, oxidative stress responses, vitamin B₃ metabolism, and vitamin B₆ metabolism. These novel findings provide insight into the etiology of some of these processes and potential targets for subsequent investigations. Data are available via ProteomeXchange with identifier PXD019505.

Prognostic nutritional index as a predictor of mortality in nontuberculous mycobacterial lung disease

Background

Although the association between nontuberculous mycobacterial lung disease (NTM-LD) and malnutrition is known, there are a few reports on the association between the nutritional score and death in patients with NTM-LD. This study investigated the association between the nutrition data at the time of NTM-LD diagnosis and death.

Methods

A retrospective study was conducted for patients with NTM-LD who visited the Maebashi Red Cross Hospital from January 2014 to December 2018. The patients were divided into the survival and death groups and analyzed statistically.

Results

The diagnostic criteria for NTM-LD were met by 150 patients. The median age was 70 years (range, 20–94 years). There were 51 (34.0%) men and 99 (66.0%) women. In the death group, the body mass index was significantly low, and there were significantly more patients with asthma. Further, computed tomography at the first visit revealed significantly fewer cases of the nodular bronchiectasis type. In the hematologic examination at the time of NTM-LD diagnosis, the white blood cell, neutrophil, and platelet counts and C-reactive protein and serum calcium levels were significantly higher in the death group, while the serum albumin level was significantly lower. In the death group, the prognostic nutritional index (PNI), calculated from the hematologic findings, was significantly lower, while the Glasgow Prognostic Score (GPS) was significantly higher. A logistic regression analysis was performed on items with significant differences, and the PNI and platelet count were independent factors predicting death.

Conclusions

PNI might be effective as a prognostic factor for NTM-LD.

Grape Seed Extract Alleviates Dexamethasone-Induced Hyperlipidemia, Lipid Peroxidation, and Hematological Alteration in Rats

The ameliorative effects of dietary natural compounds have drawn increasing attention. Dietary antioxidant is considered a common practice adopted in traditional and alternative medicine. The current study was considered to assess the ameliorative effect of grape seed extract on dexamethasone-induced hepatotoxicity in rats. Rats were injected with dexamethasone, (0.1 mg/kg; i.m.), three times per week, for 30 days. The other groups; dexamethasone (0.1 mg/kg) and grape seed extract at a dose of 200 and 400 mg/kg were given orally to rats, respectively. Dexamethasone treatment resulted in a significant elevation in liver function markers activities, lipid profile, and hematological alterations; also, a remarkable increase in hepatic lipid peroxidation marker whereas decreased antioxidant activities in rats. However, administration of grape seed extract resulted in a reversal of dexamethasone-induced lipid peroxidation, antioxidant enzyme activities, liver function markers and lipid profile, and hematological alterations. Moreover, grape seed extract demonstrated preventive action against dexamethasone-induced histopathological changes in rat liver tissues. In conclusion, grape seed extract exhibited a protective effect in rats against oxidative stress, hyperlipidemia and hematological alterations induced by dexamethasone.

Prevalence of anemia among patients with tuberculosis: A systematic review and meta-analysis

INTRODUCTION

Anemia is one of the most common hematologic problems occurs among patients with tuberculosis (TB). Many studies have been carried out estimating the prevalence of anemia among TB patients in different countries reported various results. This study aims to estimate the combined estimate of the anemia prevalence among these patients using systematic review and meta-analysis.

METHODS

Required primary studies were provided after a comprehensive and systematic search in PubMed, Scopus, Science direct, Web of Science and also Google scholar search engine. These studies were then quality assessed using Newcastle-Ottawa Scale checklist. Random effects model was applied for combining the point prevalence with 95% confidence intervals.

RESULTS

Of 41 papers entered into the meta-analysis, prevalence (95% confidence interval) of anemia among all TB patients as well as men and women were 61.53% (53.44-69.63), 66.95% (51.75-82.14) and 72.67% (60.79-84.54) respectively. Prevalence (95% confidence intervals) of mild, moderate and severe anemia were 35.67% (27.59-43.46), 31.19% (25.15-37.24) and 11.61% (7.88-15.34) respectively. In addition, prevalence (95% confidence intervals) of chronic disease anemia and iron deficiency anemia were 49.82% (15.58-84.07) and 20.17% (6.68-33.65) respectively.

CONCLUSION

Prevalence of anemia among TB patients was high especially among women. More than 43% of these patients suffered from moderate and severe anemia and about half of them had chronic disease anemia.

APACHE-II score for anti-tuberculosis tolerance in critically ill patients: a retrospective study

Background

To investigate the status of anti-tuberculosis treatment in critically ill patients, and to explore the value of APACHE-II score in guiding anti-tuberculosis treatment.

Methods

This analysis included critically ill patients with tuberculosis. The utility of APACHE-II score for predicting drug withdrawal was evaluated using receiver operating characteristic (ROC) curve analysis.

Results

Among 320 patients enrolled (58 ± 22 years; 256 males), 147 (45.9%) had drugs withdrawn. The drug withdrawal group had higher APACHE-II score (median [interquartile range]: 21 [3–52] vs. 17 [4–42] points), higher CD4%, lower hemoglobin level, higher rates of chronic obstructive pulmonary disease (COPD) and chronic renal failure, and lower rate of extrapulmonary tuberculosis (P < 0.05). Logistic regression identified APACHE-II score > 18 (odds ratio [95% confidence interval]: 2.099 [1.321–3.334], P < 0.01), COPD (1.913 [1.028–3.561], P < 0.05) and hemoglobin level (0.987 [0.977–0.997], P < 0.05) as independent factors associated with drug withdrawal. At an optimal cutoff of 18.5, the sensitivity, specificity, positive predictive value and negative predictive value of APACHE-II score for predicting drug withdrawal was 59.2, 61.8, 56.9 and 64.1%, respectively.

Conclusions

APACHE-II score > 18 points might predict patient tolerance of anti-tuberculosis treatment.

Evaluation of Adverse Reactions Induced by Anti-Tuberculosis Drugs in Hospital Pulau Pinang

Background

The use of multi-drug regimens in tuberculosis (TB) treatment has been associated with undesirable adverse drug reactions (ADRs). This study aims to assess the incidence and impact of ADRs on TB treatment in Hospital Pulau Pinang.

Methods

This cross-sectional study was conducted via retrospective review of outpatients’ medical records. Details regarding ADRs were identified by a pharmacist and verified by a consultant respiratory physician.

Results

A total of 91 cases, out of 210 patients enrolled in this study, were detected with 75 patients (35.7%) experienced at least one ADR. The three most common ADRs detected were cutaneous adverse drug reactions (CADRs) (21.0%), drug-induced hepatitis (DIH) (7.1%) and gastrointestinal disturbance (4.8%). Pyrazinamide was the most common causative agent and 15.7% of all TB patients required treatment modification due to ADRs. Females were shown to have a higher tendency to develop ADRs than the males in this study (P = 0.009). The development of ADRs was shown not to affect the TB treatment outcomes (P = 0.955).

Conclusion

The incidence of ADRs in this study was high so it is important to identify the risk factors for ADRs and the individuals who have those risk factors when initiating anti-TB drugs. These individuals require special attention when anti-TB drugs are initiated.

Delayed diagnosis of extrapulmonary tuberculosis presenting as fever of unknown origin in an intermediate-burden country

Background

Tuberculosis (TB), especially extrapulmonary tuberculosis (EPTB), is an important cause of fever of unknown origin (FUO) in TB-burdened areas. Little information is known about patients with EPTB with clinical features presenting as FUO and about the factor of delaying the diagnosis.

Methods

We retrospectively analyzed EPTB patients who were referred with FUO at 3 university-affiliated hospitals over 8 years (2010–2017). The subjects were assigned to groups of early diagnosis and delayed diagnosis within 3 days of an initial comprehensive evaluation from the referral. Clinical and laboratory variables were compared between the groups.

Results

A total of 95 patients with febrile EPTB were included. Localizing symptoms and/or signs suggestive of anatomy were identified in 62.1% of the patients. Concurrent lung involvement by TB was presented by 49.5% (47/95) of the patients, and only 23.4% of them showed typical findings of pulmonary TB on simple chest X-ray. Most of the patients showed abnormal lesions on cross-sectional CT (98.9%) and MRI (100%). The clinical variables and blood test results of patients were not significantly different between the two groups. The less typical imaging finding of EPTB on CT (38.5% vs. 79.0%) and MRI (37.5% vs. 79.0%) in the delayed diagnosis group was a risk factor for delayed diagnosis.

Conclusion

Febrile EPTB referred as FUO showed nonspecific clinical manifestations. The active application of cross-sectional imaging tests according to clinical clues or randomly in the absence of local manifestations, combined with invasive diagnostic approaches even for atypical presentations may lead to an earlier diagnosis of febrile EPTB.

Pulmonary nocardiosis masquerading renascence of tuberculosis in an immunocompetent host: a case report from Nepal

BACKGROUND

Pulmonary nocardiosis is an opportunistic infection in an immunocompromised patient; however, often neglected in the immunocompetent patient from the diagnosis considerations.

CASE PRESENTATIONS

We describe a case of pulmonary nocardiosis masquerading renascence of tuberculosis, in a 51-years-Nepali farmer. After a 6 month of presumed successful antitubercular therapy; the patient develops the clinical presentations and radiological features showing similarities with that of tuberculosis and malignancy. MTB complex was not detected with Xpert MTB/RIF assay and cytological examinations were negative for the malignant cells, however. The Ziehl-Neelsen staining of the broncho-alveolar-lavage revealed acid-fast, thin branching filamentous organisms suggestive Nocardia spp. Further, identifications and susceptibility pattern against recommended antibiotics were assessed as per the CLSI guidelines. The case was then, subsequently, diagnosed as pulmonary nocardiosis. Trimethoprim-sulfamethoxazole was prescribed for 12 months. The patient underwent progressive changes and no relapse was noted in a periodic follow-up.

CONCLUSIONS

This case underscores that pulmonary nocardiosis requires diagnostic considerations, regardless of a patient's immunologic status and other mimicking infections.

Methionine and vitamin B-complex ameliorate antitubercular drugs-induced toxicity in exposed patients

Tuberculosis therapy utilizes drugs that while effective cause treatment‐related toxicity. Modulation of antitubercular drugs‐induced toxicity by methionine and vitamin B‐complex in patients was evaluated. 285 treatment‐naïve tuberculosis patients at the Chest Clinics of Infectious Diseases Hospital, Yaba and General Hospital, Lagos in Lagos, Nigeria was prospectively recruited and allotted into test (antitubercular medicines, methionine and vitamin B‐complex) and control groups (antitubercular medicines). Data on adverse drug reactions and blood samples were collected at initiation, 2 months and 6 months, and then analyzed. Red blood cells and packed cell volume were significantly higher (P < 0.05) in the test group compared to control at 6 months of therapy. At the end of 2 months, results showed a significant decrease (P < 0.001) in aspartate aminotransferase, alkaline phosphatase, alanine aminotransferase, urea, creatinine and total bilirubin in the test group compared to control. Reduced glutathione and superoxide dismutase were significantly increased (P < 0.001) and malondialdehyde significantly decreased (P < 0.001) in the test versus control groups at the end of 2 and 6 months. Adverse drug reactions were significantly lower (P < 0.001) in the test group (32.4%) compared to control group (56.2%), with 1 death. Hepatotoxicity was significantly higher (P = 0.026) in control (6.9%), compared to test group (0%). Alcohol and cigarette smoking were significantly (P = 0.019 and P = 0.027) associated with the occurrence of adverse drug reactions. Methionine and vitamin B‐complex modulated hepatic, renal, hematological, antioxidant indices and adverse effects in patients administered antitubercular medicines. Such interventions can enhance compliance and better treatment outcomes in tuberculosis patients.

Disseminated Nocardiosis in renal transplant recipient under therapy for pulmonary tuberculosis: a case report

Background

Nocardiosis is an opportunistic infection in a patient with underlying immune suppression and organ transplant. Clinical syndromes are varied and ranges from pulmonary, disseminated, cutaneous along with central nervous system involvement.

Case presentation

Herein, we report a rare case of disseminated pulmonary nocardiosis with cerebral manifestation in a 66 year-old-Nepali farmer; with a history of renal transplantation and undergoing therapy for pulmonary tuberculosis. Radiographic imaging revealed multiple opacities of varying sizes in bilateral lung field mediastinal, retroperitoneal lymphadenopathy, and ill-defined lesion with surrounding edema seen in left occipitoparietal region of brain. Bacteriological assessments of bronchoalveolar lavage and purulent fluid extracted intra-operatively from the lesion confirmed the case as Nocardiosis.

Conclusion

Disseminated Pulmonary nocardiosis with central nervous system involvement carries a poor prognosis. However, early diagnosis of the case, the administration of appropriate antibiotic, stereotactic aspiration alone or craniotomy has a successful outcomes even in a post renal transplant patient treated with anti tuberculosis treatment.

Single-centre experience of granulomatous interstitial nephritis-time for a new approach?

Background: Differentiating between renal-limited sarcoidosis and tuberculosis (TB) infection as a cause of granulomatous interstitial nephritis (GIN) can be difficult. This series compares clinical features and response to treatment between the different underlying aetiologies in order to propose a management algorithm for GIN to assist with diagnosis and treatment.

Methods: This retrospective study reports on all patients presenting with a histological diagnosis of GIN between 2000 and 2012 at our unit.

Results: Twenty-one patients were identified, 57% were male and the mean age was 53 years. Eight cases were associated with sarcoidosis with evidence of extra-renal disease and five with renal-limited sarcoidosis. Five patients had GIN that may have been related to TB infection or to renal-limited sarcoidosis, and three were idiopathic or drug related. All those with sarcoidosis were treated with steroids and renal function, as measured by estimated glomerular filtration rate (eGFR), improved from a mean of 24 mL/min at baseline to 37 mL/min at 1 year. Baseline eGFR was 19 mL/min in those with possible TB infection. Four received steroids as well as anti-TB drugs. Anti-TB therapy was delayed in four patients by a mean of 22 months due to difficulties in diagnosis. Two patients with TB developed end-stage kidney disease and the remaining three patients had a mean eGFR of 28 mL/min at 1 year.

Conclusions: This series represents the largest cohort of patients with GIN in the UK and supports previous findings that patients with sarcoid have a favourable outcome with steroid treatment. Those with TB have an inferior prognosis, perhaps due to delayed diagnosis. We suggest an algorithm when investigating a diagnosis of GIN with the aim of expediting diagnosis and considering a trial of anti-TB therapy in order to prevent deterioration of renal function.

The early secreted antigenic target of 6 kD of Mycobacterium tuberculosis inhibits the proliferation and differentiation of human peripheral blood CD34+ cells

Abnormalities in hematopoiesis are common in tuberculosis patients and highly prevalent in AIDS patients with tuberculosis coinfection. To explore the potential role of the early secreted antigenic target of 6-kD (ESAT-6) of Mycobacterium tuberculosis (Mtb) in abnormal hematopoiesis in tuberculosis, we studied the effect of ESAT-6 on proliferation and differentiation of in vitro-expanded CD34⁺ cells isolated from the peripheral blood of the healthy donors. ESAT-6 but not control protein antigen 85A (Ag85A) of Mtb inhibited the proliferation of CD34⁺ cell derived peripheral blood stem/progenitor cells (PBSPC) in a dose dependent manner when determined by MTT-assay. ESAT-6 but not Ag85A reduced the number of colony forming cells (CFC) of PBSPC by 60-90% as determined by CFC assay by incubation of CD34⁺ cells in a semi-solid cellulose media in the presence of cytokine cocktail for two weeks. ESAT-6 but not Ag85A increased the percentages of the Annexin-V positive cells and enhanced the cleavage of caspase-3 in PBSPC in a time and dose dependent manner as determined by flow cytometry and Western blot analysis, respectively. ESAT-6 also inhibited murine bone marrow derived non-adherent cell proliferation in response to granulocyte-macrophage colony stimulating factor treatment. We conclude that ESAT-6, an essential virulence factor of Mtb, may contribute to the abnormal hematopoiesis of tuberculosis patients by inhibiting the proliferation and differentiation of hematopoietic cells via apoptosis.