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Lu HJ, Guo D, Wei QQ. Potential of Neuroinflammation-Modulating Strategies in Tuberculous Meningitis: Targeting Microglia. Aging Dis 2024; 15:1255-1276. [PMID: 37196131 PMCID: PMC11081169 DOI: 10.14336/ad.2023.0311] [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: 12/09/2022] [Accepted: 03/11/2023] [Indexed: 05/19/2023] Open
Abstract
Tuberculous meningitis (TBM) is the most severe complication of tuberculosis (TB) and is associated with high rates of disability and mortality. Mycobacterium tuberculosis (M. tb), the infectious agent of TB, disseminates from the respiratory epithelium, breaks through the blood-brain barrier, and establishes a primary infection in the meninges. Microglia are the core of the immune network in the central nervous system (CNS) and interact with glial cells and neurons to fight against harmful pathogens and maintain homeostasis in the brain through pleiotropic functions. However, M. tb directly infects microglia and resides in them as the primary host for bacillus infections. Largely, microglial activation slows disease progression. The non-productive inflammatory response that initiates the secretion of pro-inflammatory cytokines and chemokines may be neurotoxic and aggravate tissue injuries based on damages caused by M. tb. Host-directed therapy (HDT) is an emerging strategy for modulating host immune responses against diverse diseases. Recent studies have shown that HDT can control neuroinflammation in TBM and act as an adjunct therapy to antibiotic treatment. In this review, we discuss the diverse roles of microglia in TBM and potential host-directed TB therapies that target microglia to treat TBM. We also discuss the limitations of applying each HDT and suggest a course of action for the near future.
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Affiliation(s)
- Huan-Jun Lu
- Institute of Special Environmental Medicine, Nantong University, Jiangsu, China
| | - Daji Guo
- Department of Neurology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qian-Qi Wei
- Department of Infectious Diseases, General Hospital of Tibet Military Command, Xizang, China
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Tomidy J, Satriadinatha GBY, Liwang FK, Maharani K, Imran D, Estiasari R. Prognostic identifier of cerebrovascular complications in tuberculous meningitis: Meta-analysis. J Stroke Cerebrovasc Dis 2023; 32:107371. [PMID: 37738916 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107371] [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: 01/03/2023] [Revised: 09/03/2023] [Accepted: 09/12/2023] [Indexed: 09/24/2023] Open
Abstract
INTRODUCTION Cerebrovascular complications could occur in 15-57 % of patients with tuberculous meningitis (TBM). It is crucial to rapidly identify TBM patients who are at risk for stroke. This study aimed to find predictors of stroke in patients with TBM. METHODS This systematic review and meta-analysis were done using literature searches through online databases up to April 30th, 2022. Three independent authors performed literature screening, data extraction, and critical appraisal of the studies. Eight studies involving 1535 samples were included. RESULTS We analyzed data regarding demographic, comorbidity, clinical presentation, radiologic, and laboratory parameters. Overall, clinical presentation that showed outcome difference was found in patients with findings of vomiting (OR = 2.71, 95 % CI: 1.30-5.63), cranial nerve deficit (OR = 4.10, 95 % CI: 1.83-9.21), focal deficit (OR = 5.56, 95 % CI: 2.24-13.79), and altered consciousness (OR = 1.90, 95 % CI: 1.24-2.92). Some comorbidities showed significant differences such as diabetes mellitus (OR = 2.58, 95 % CI: 1.51-4.41), hypertension (OR = 5.73, 95 % CI: 3.36-9.77), ischemic heart disease (OR = 2.18, 95 % CI: 1.02-4.63), and smoking (OR = 2.65, 95 % CI: 1.22-5.77). Two radiological changes shown to have significantly higher proportions are hydrocephalus (OR = 2.50, 95 % CI: 1.74-3.58) and meningeal enhancements (OR = 3.99, 95 % CI: 1.73-9.20). CONCLUSION Our analysis indicated that clinical presentations of vomiting, cranial nerve deficit, focal deficit, altered consciousness; comorbidity of diabetes mellitus, hypertension, smoking history, ischemic heart disease; and radiological findings of meningeal enhancement and hydrocephalus showed significant association with stroke incidence in tuberculous meningitis.
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Affiliation(s)
- Julianto Tomidy
- Department of Neurology, Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia, Jl. Diponegoro No.71, Jakarta 10430, Indonesia
| | - Gede Bagus Yoga Satriadinatha
- Department of Neurology, Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia, Jl. Diponegoro No.71, Jakarta 10430, Indonesia
| | - Filbert Kurnia Liwang
- Department of Neurology, Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia, Jl. Diponegoro No.71, Jakarta 10430, Indonesia
| | - Kartika Maharani
- Department of Neurology, Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia, Jl. Diponegoro No.71, Jakarta 10430, Indonesia
| | - Darma Imran
- Department of Neurology, Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia, Jl. Diponegoro No.71, Jakarta 10430, Indonesia
| | - Riwanti Estiasari
- Department of Neurology, Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia, Jl. Diponegoro No.71, Jakarta 10430, Indonesia.
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Griego A, Scarpa E, De Matteis V, Rizzello L. Nanoparticle delivery through the BBB in central nervous system tuberculosis. IBRAIN 2023; 9:43-62. [PMID: 37786519 PMCID: PMC10528790 DOI: 10.1002/ibra.12087] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 12/16/2022] [Accepted: 12/19/2022] [Indexed: 10/04/2023]
Abstract
Recent advances in Nanotechnology have revolutionized the production of materials for biomedical applications. Nowadays, there is a plethora of nanomaterials with potential for use towards improvement of human health. On the other hand, very little is known about how these materials interact with biological systems, especially at the nanoscale level, mainly because of the lack of specific methods to probe these interactions. In this review, we will analytically describe the journey of nanoparticles (NPs) through the brain, starting from the very first moment upon injection. We will preliminarily provide a brief overlook of the physicochemical properties of NPs. Then, we will discuss how these NPs interact with the body compartments and biological barriers, before reaching the blood-brain barrier (BBB), the last gate guarding the brain. Particular attention will be paid to the interaction with the biomolecular, the bio-mesoscopic, the (blood) cellular, and the tissue barriers, with a focus on the BBB. This will be framed in the context of brain infections, especially considering central nervous system tuberculosis (CNS-TB), which is one of the most devastating forms of human mycobacterial infections. The final aim of this review is not a collection, nor a list, of current literature data, as it provides the readers with the analytical tools and guidelines for the design of effective and rational NPs for delivery in the infected brain.
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Affiliation(s)
- Anna Griego
- Department of Pharmaceutical SciencesUniversity of MilanMilanItaly
- The National Institute of Molecular Genetics (INGM)MilanItaly
| | - Edoardo Scarpa
- Department of Pharmaceutical SciencesUniversity of MilanMilanItaly
- The National Institute of Molecular Genetics (INGM)MilanItaly
| | - Valeria De Matteis
- Department of Mathematics and Physics “Ennio De Giorgi”University of SalentoLecceItaly
| | - Loris Rizzello
- Department of Pharmaceutical SciencesUniversity of MilanMilanItaly
- The National Institute of Molecular Genetics (INGM)MilanItaly
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Elafros MA, Bwalya C, Muchanga G, Mwale M, Namukanga N, Birbeck GL, Chomba M, Mugala-Mulenga A, Kvalsund MP, Sikazwe I, Saylor DR, Winch PJ. A qualitative study of factors resulting in care delays for adults with meningitis in Zambia. Trans R Soc Trop Med Hyg 2022; 116:1138-1144. [PMID: 35653707 PMCID: PMC9717355 DOI: 10.1093/trstmh/trac049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/27/2022] [Accepted: 05/11/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Meningitis causes significant mortality in regions with high comorbid HIV and TB. Improved outcomes are hindered by limited understanding of factors that delay adequate care. METHODS In-depth interviews of patients admitted to the University Teaching Hospital with suspected meningitis, their caregivers, doctors and nurses were conducted. Patient/caregiver interviews explored meningitis understanding, treatment prior to admission and experiences since admission. Provider interviews addressed current and prior experiences with meningitis patients and hospital barriers to care. A conceptual framework based on the Three Delays Model identified factors that delayed care. RESULTS Twenty-six patient/caregiver, eight doctor and eight nurse interviews occurred. Four delays were identified: in-home care; transportation to a health facility; clinic/first-level hospital care; and third-level hospital. Overcrowding and costly diagnostic testing delayed outpatient care; 23% of patients began with treatment inside the home due to prior negative experiences with biomedical care. Admission occurred after multiple clinic visits, where subsequent delays occurred during testing and treatment. CONCLUSIONS Delays in care from home to hospital impair quality meningitis care in Zambia. Interventions to improve outcomes must address patient, community and health systems factors. Patient/caregiver education regarding signs of meningitis and indications for care-seeking are warranted to reduce treatment delays.
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Affiliation(s)
- Melissa A Elafros
- Department of Neurology, University of Michigan, Ann Arbor, 48109 Michigan, USA
| | - Chiti Bwalya
- Maryland Global Initiatives Corporation (MGIC), Lusaka, Zambia
| | | | - Mwangala Mwale
- Maryland Global Initiatives Corporation (MGIC), Lusaka, Zambia
| | | | - Gretchen L Birbeck
- Department of Neurology, University of Rochester, Rochester, 14642 New York, USA
- University Teaching Hospitals Children's Hospital, 10101 Lusaka, Zambia
| | - Mashina Chomba
- Department of Internal Medicine, University of Zambia, School of Medicine, 10101 Lusaka, Zambia
| | | | - Michelle P Kvalsund
- Department of Neurology, University of Rochester, Rochester, 14642 New York, USA
- Department of Internal Medicine, University of Zambia, School of Medicine, 10101 Lusaka, Zambia
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, 10101 Lusaka, Zambia
| | - Deanna R Saylor
- Department of Internal Medicine, University of Zambia, School of Medicine, 10101 Lusaka, Zambia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Peter J Winch
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, 21205 Maryland, USA
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Ma Q, Yi Y, Liu T, Wen X, Shan F, Feng F, Yan Q, Shen J, Yang G, Shi Y. MRI-based radiomics signature for identification of invisible basal cisterns changes in tuberculous meningitis: a preliminary multicenter study. Eur Radiol 2022; 32:8659-8669. [PMID: 35748898 PMCID: PMC9226270 DOI: 10.1007/s00330-022-08911-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 04/27/2022] [Accepted: 05/27/2022] [Indexed: 12/04/2022]
Abstract
Objective To develop and evaluate a radiomics signature based on magnetic resonance imaging (MRI) from multicenter datasets for identification of invisible basal cisterns changes in tuberculous meningitis (TBM) patients. Methods Our retrospective study enrolled 184 TBM patients and 187 non-TBM controls from 3 Chinese hospitals (training dataset, 158 TBM patients and 159 non-TBM controls; testing dataset, 26 TBM patients and 28 non-TBM controls). nnU-Net was used to segment basal cisterns in fluid-attenuated inversion recovery (FLAIR) images. Subsequently, radiomics features were extracted from segmented basal cisterns in FLAIR and T2-weighted (T2W) images. Feature selection was carried out in three steps. Support vector machine (SVM) and logistic regression (LR) classifiers were applied to construct the radiomics signature to directly identify basal cisterns changes in TBM patients. Finally, the diagnostic performance was evaluated by the receiver operating characteristic (ROC) curve analysis, calibration curve, and decision curve analysis (DCA). Results The segmentation model achieved the mean Dice coefficients of 0.920 and 0.727 in the training and testing datasets, respectively. The SVM model with 7 T2WI–based radiomics features achieved best discrimination capability for basal cisterns changes with an AUC of 0.796 (95% CI, 0.744–0.847) in the training dataset, and an AUC of 0.751 (95% CI, 0.617–0.886) with good calibration in the testing dataset. DCA confirmed its clinical usefulness. Conclusion The T2WI–based radiomics signature combined with deep learning segmentation could provide a fully automatic, non-invasive tool to identify invisible changes of basal cisterns, which has the potential to assist in the diagnosis of TBM. Key Points • The T2WI–based radiomics signature was useful for identifying invisible basal cistern changes in TBM. • The nnU-Net model achieved acceptable results for the auto-segmentation of basal cisterns. • Combining radiomics and deep learning segmentation provided an automatic, non-invasive approach to assist in the diagnosis of TBM.
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Affiliation(s)
- Qiong Ma
- Department of Radiology, Shanghai Public Health Clinical Center, Fudan University, Shanghai, China.,Shanghai Institute of Medical Imaging, Fudan University, Shanghai, China
| | - Yinqiao Yi
- Shanghai Key Laboratory of Magnetic Resonance, East China Normal University, Shanghai, China
| | - Tiejun Liu
- Department of Radiology, Liuzhou People's Hospital, Liuzhou, Guangxi Zhuang Autonomous Region, China
| | - Xinnian Wen
- Department of Radiology, Guangxi Zhuang Autonomous Region Chest Hospital, Liuzhou, Guangxi Zhuang Autonomous Region, China
| | - Fei Shan
- Department of Radiology, Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
| | - Feng Feng
- Department of Radiology, Nantong Tumor Hospital, Nantong, Jiangsu, China
| | - Qinqin Yan
- Department of Radiology, Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
| | - Jie Shen
- Department of Radiology, Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
| | - Guang Yang
- Shanghai Key Laboratory of Magnetic Resonance, East China Normal University, Shanghai, China.
| | - Yuxin Shi
- Department of Radiology, Shanghai Public Health Clinical Center, Fudan University, Shanghai, China.
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Tuberculous Meningitis in Children: Reducing the Burden of Death and Disability. Pathogens 2021; 11:pathogens11010038. [PMID: 35055986 PMCID: PMC8778027 DOI: 10.3390/pathogens11010038] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/13/2021] [Accepted: 12/21/2021] [Indexed: 11/29/2022] Open
Abstract
Tuberculous meningitis disproportionately affects young children. As the most devastating form of tuberculosis, it is associated with unacceptably high rates of mortality and morbidity even if treated. Challenging to diagnose and treat, tuberculous meningitis commonly causes long-term neurodisability in those who do survive. There remains an urgent need for strengthened surveillance, improved rapid diagnostics technology, optimised anti-tuberculosis drug therapy, investigation of new host-directed therapy, and further research on long-term functional and neurodevelopmental outcomes to allow targeted intervention. This review focuses on the neglected field of paediatric tuberculous meningitis and bridges current clinical gaps with research questions to improve outcomes from this crippling disease.
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Mason S, Solomons R. CSF Metabolomics of Tuberculous Meningitis: A Review. Metabolites 2021; 11:661. [PMID: 34677376 PMCID: PMC8541251 DOI: 10.3390/metabo11100661] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/20/2021] [Accepted: 09/24/2021] [Indexed: 02/07/2023] Open
Abstract
From the World Health Organization's global TB report for 2020, it is estimated that in 2019 at least 80,000 children (a particularly vulnerable population) developed tuberculous meningitis (TBM)-an invariably fatal disease if untreated-although this is likely an underestimate. As our latest technologies have evolved-with the unprecedented development of the various "omics" disciplines-a mountain of new data on infectious diseases have been created. However, our knowledge and understanding of infectious diseases are still trying to keep pace. Metabolites offer much biological information, but the insights they permit can be difficult to derive. This review summarizes current metabolomics studies on cerebrospinal fluid (CSF) from TBM cases and collates the metabolic data reported. Collectively, CSF metabolomics studies have identified five classes of metabolites that characterize TBM: amino acids, organic acids, nucleotides, carbohydrates, and "other". Taken holistically, the information given in this review serves to promote the mechanistic action of hypothesis generation that will drive and direct future studies on TBM.
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Affiliation(s)
- Shayne Mason
- Human Metabolomics, Faculty of Natural and Agricultural Sciences, North-West University, Potchefstroom 2531, South Africa
| | - Regan Solomons
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg 7505, South Africa;
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van Toorn R, Zaharie SD, Seddon JA, van der Kuip M, Marceline van Furth A, Schoeman JF, Solomons RS. The use of thalidomide to treat children with tuberculosis meningitis: A review. Tuberculosis (Edinb) 2021; 130:102125. [PMID: 34500217 DOI: 10.1016/j.tube.2021.102125] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/26/2021] [Accepted: 09/02/2021] [Indexed: 11/17/2022]
Abstract
Much of the morbidity and mortality caused by tuberculous meningitis (TBM) is mediated by a dysregulated immune response. Effective host-directed therapy is therefore critical to improve survival and clinical outcomes. Currently only one host-directed therapy (HDT), corticosteroids, is proven to improve mortality. However, there is no evidence that corticosteroids reduce morbidity and the mechanism of action for mortality reduction is uncertain. Further, it has no proven benefit in HIV co-infected individuals. One promising host-directed therapy approach is to restrict the immunopathology arising from tumour necrosis factor (TNF)-α excess is via TNF-α inhibitors. There are accumulating data on the role of thalidomide, anti-TNF-α monoclonal antibodies (infliximab, adalimumab) and the soluble TNF-α receptor (etanercept) in TBM treatment. Thalidomide was developed nearly seventy years ago and has been a highly controversial drug. Birth defects and toxic adverse effects have limited its use but an improved understanding of its immunological mechanism of action suggest that it may have a crucial role in regulating the destructive host response seen in inflammatory conditions such as TBM. Observational studies at our institution found low dosage adjunctive thalidomide safe in treating tuberculous mass lesions and blindness related to optochiasmatic arachnoiditis, with good clinical and radiological response. In this review, we discuss possible mechanisms of action for thalidomide, based on our clinico-radiologic experience and post-mortem histopathological work. We also propose a rationale for its use in the treatment of certain TBM-related complications.
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Affiliation(s)
- Ronald van Toorn
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Stefan-Dan Zaharie
- Department of Anatomical Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; National Health Laboratory Services, South Africa
| | - James A Seddon
- Department of Infectious Disease, Imperial College London, United Kingdom; Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Martijn van der Kuip
- Department of Pediatric Infectious Diseases and Immunology, Amsterdam Infection & Immunity Institute, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - A Marceline van Furth
- Department of Pediatric Infectious Diseases and Immunology, Amsterdam Infection & Immunity Institute, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Johan F Schoeman
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Regan S Solomons
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
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Hai HT, Sabiiti W, Thu DDA, Phu NH, Gillespie SH, Thwaites GE, Thuong NTT. Evaluation of the molecular bacterial load assay for detecting viable Mycobacterium tuberculosis in cerebrospinal fluid before and during tuberculous meningitis treatment. Tuberculosis (Edinb) 2021; 128:102084. [PMID: 33965677 PMCID: PMC8204225 DOI: 10.1016/j.tube.2021.102084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 04/23/2021] [Accepted: 04/26/2021] [Indexed: 12/03/2022]
Abstract
New tools to monitor treatment response and predict outcome from tuberculous meningitis (TBM) are urgently required. We retrospectively evaluated the 16S rRNA-based molecular bacterial load assay (MBLA) to quantify viable Mycobacterium tuberculosis in serial cerebrospinal fluid (CSF) from adults with TBM. 187 CSF samples were collected before and during the first two months of treatment from 99 adults TBM, comprising 56 definite, 43 probable or possible TBM, and 18 non-TBM and preserved at −80°C prior to MBLA. We compared MBLA against MGIT culture, GeneXpert MTB/RIF (Xpert) and Ziehl-Neelsen (ZN) smear. Before treatment, MBLA was positive in 34/99 (34.3%), significantly lower than MGIT 47/99 (47.5%), Xpert 51/99 (51.5%) and ZN smear 55/99 (55.5%). After one month of treatment, MBLA and MGIT were positive in 3/38 (7.9%) and 4/38 (10.5%), respectively, whereas Xpert and ZN smear remained positive in 19/38 (50.0%) and 18/38 (47.4%). In summary, MBLA was less likely to detect CSF bacteria before the start of treatment compared with MGIT culture, Xpert and ZN smear. MBLA and MGIT positivity fell during treatment because of detecting only viable bacteria, whereas Xpert and ZN smear remained positive for longer because of detecting both live and dead bacteria. Sample storage and processing may have reduced MBLA-detectable viable bacteria; and sampling earlier in treatment may yield more useful results. Prospective studies with CSF sampling after 1–2 weeks are warranted.
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Affiliation(s)
- Hoang Thanh Hai
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | - Wilber Sabiiti
- School of Medicine, Division of Infection and Global Health, University of St Andrews, United Kingdom
| | - Do Dang Anh Thu
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | - Nguyen Hoan Phu
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam; Hospital for Tropical Diseases, Ho Chi Minh City, Viet Nam
| | - Stephen H Gillespie
- School of Medicine, Division of Infection and Global Health, University of St Andrews, United Kingdom
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam; Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Nguyen Thuy Thuong Thuong
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam; Nuffield Department of Medicine, University of Oxford, United Kingdom.
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