1
|
Musteikienė G, Miliauskas S, Zaveckienė J, Urbonienė D, Vitkauskienė A, Žemaitis M, Naudžiūnas A. Is analysis of inflammatory biomarkers and lymphocyte subpopulations useful in prediction of tuberculosis treatment outcomes? J Clin Tuberc Other Mycobact Dis 2021; 25:100275. [PMID: 34541339 PMCID: PMC8436121 DOI: 10.1016/j.jctube.2021.100275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Analysis of inflammatory biomarkers and lymphocytes during the treatment of tuberculosis (TB) could yield findings that influence the routine clinical practice and use of new anti-TB drugs. This study aimed to evaluate whether the selected biomarkers-soluble intercellular adhesion molecule type 1, soluble urokinase-type plasminogen activator receptor (suPAR), and C-reactive protein (CRP)-and T-cell subpopulations are useful for predicting culture conversion, treatment outcomes, and the extent of radiological lesions (calculated using X-ray score) in patients with drug-sensitive pulmonary TB. This study included 62 patients with drug-sensitive pulmonary TB. CRP and suPAR levels significantly decreased after 1 month of treatment. Before treatment initiation, CRP and suPAR levels were significantly higher in patients without culture conversion; however, none of the selected host biomarkers appeared to significantly influence the conversion status or treatment outcomes. Some lymphocyte subpopulations were correlated with X-ray scores before TB treatment initiation, but lung destruction, as determined using X-ray scores, showed the highest correlation with the baseline CRP value. We conclude that selected host biomarkers have a very limited role in predicting TB treatment outcomes and culture conversion and do not appear to be superior to CRP in monitoring TB treatment.
Collapse
Affiliation(s)
- Greta Musteikienė
- Department of Pulmonology, Medical Academy, Lithuanian University of Health Sciences, Eiveniu 2, LT-50161 Kaunas, Lithuania
| | - Skaidrius Miliauskas
- Department of Pulmonology, Medical Academy, Lithuanian University of Health Sciences, Eiveniu 2, LT-50161 Kaunas, Lithuania
| | - Jurgita Zaveckienė
- Department of Radiology, Medical Academy, Lithuanian University of Health Sciences, Eiveniu 2, LT-50161 Kaunas, Lithuania
| | - Daiva Urbonienė
- Department of Laboratory Medicine, Medical Academy, Lithuanian University of Health Sciences, Eiveniu 2, LT-50161 Kaunas, Lithuania
| | - Astra Vitkauskienė
- Department of Laboratory Medicine, Medical Academy, Lithuanian University of Health Sciences, Eiveniu 2, LT-50161 Kaunas, Lithuania
| | - Marius Žemaitis
- Department of Pulmonology, Medical Academy, Lithuanian University of Health Sciences, Eiveniu 2, LT-50161 Kaunas, Lithuania
| | - Albinas Naudžiūnas
- Department of Internal Medicine, Medical Academy, Lithuanian University of Health Sciences, Eiveniu 2, LT-50161 Kaunas, Lithuania
| |
Collapse
|
2
|
Goovaerts O, Massinga-Loembé M, Ondoa P, Ceulemans A, Worodria W, Mayanja-Kizza H, Colebunders R, Kestens L. Lack of elevated pre-ART elastase-ANCA levels in patients developing TB-IRIS. PLoS One 2020; 15:e0244800. [PMID: 33382831 PMCID: PMC7775098 DOI: 10.1371/journal.pone.0244800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 12/16/2020] [Indexed: 11/19/2022] Open
Abstract
Background Tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) in HIV-TB co-infected patients receiving antiretroviral therapy (ART) has been linked to neutrophil activation. Anti-neutrophil cytoplasmic antibodies (ANCAs) are also associated with neutrophil activation. Since ANCAs are reportedly skewed in TB and HIV infections, we investigated plasma levels of 7 ANCAs in TB-IRIS patients. Methods We retrospectively compared 17 HIV-TB patients who developed TB-IRIS with controls of similar CD4 count, age and gender who did not (HIV+TB+ n = 17), HIV-infected patients without TB (HIV+TB-, n = 17) and 10 HIV-negative (HIV-TB-) controls. Frozen plasma was collected before ART, at 3 and 9 months of ART, and examined by ELISA for levels of 7 ANCAs directed against; Proteinase 3 (PR3), Myeloperoxidase (MPO), Permeability-increasing protein (BPI), Elastase, Cathepsin, Lysozyme, and Lactoferrin. Results Compared to HIV+TB+ controls, pre-ART anti-elastase levels were lower in TB-IRIS patients (p = 0.026) and HIV-TB- controls (p = 0.044), whereas other ANCAs did not show significant differences between groups at any time point. A significant decrease over time could be observed in TB-IRIS patients during ART for anti -PR3 (p = 0.027), -lysozyme (p = 0.011), and -lactoferrin (p = 0.019). Conversely, HIV+TB+ controls showed a significant decrease over time for anti -MPO (p = 0.002), -lyzosyme (p = 0.002) and -elastase (p < 0.001). Conclusion The lack of elevated anti-elastase levels in TB-IRIS patients as opposed to HIV+TB+ controls correspond to previous findings of lowered immune capacity in patients that will develop TB-IRIS. This may suggest a specific role for anti-elastase, elastase or even matrix-metalloproteinases in TB-IRIS. The precise dynamics of neutrophil activation in HIV-TB merits further investigation and could provide more insight in the early mechanisms leading up to TB-IRIS.
Collapse
Affiliation(s)
- Odin Goovaerts
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- * E-mail:
| | - Marguerite Massinga-Loembé
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Centre de Recherches Médicales de Lambaréné (CERMEL), Albert Schweitzer Hospital, Lambarene, Gabon
- Institut für Tropenmedizin,Universität Tübingen, Tübingen, Germany
| | - Pascale Ondoa
- African Society for Laboratory Medicine, Addis Ababa, Ethiopia
- Amsterdam Institute of Global Health and Development, Academic Medical Center, Department of Global Health, University of Amsterdam, Amsterdam, The Netherlands
| | - Ann Ceulemans
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - William Worodria
- Department of Medicine, Mulago Hospital, Kampala, Uganda
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Infectious Diseases Network for Treatment and Research in Africa (INTERACT), Kampala, Uganda
| | - Harriet Mayanja-Kizza
- Department of Medicine, Mulago Hospital, Kampala, Uganda
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Luc Kestens
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | | |
Collapse
|
3
|
Quinn CM, Poplin V, Kasibante J, Yuquimpo K, Gakuru J, Cresswell FV, Bahr NC. Tuberculosis IRIS: Pathogenesis, Presentation, and Management across the Spectrum of Disease. Life (Basel) 2020; 10:E262. [PMID: 33138069 PMCID: PMC7693460 DOI: 10.3390/life10110262] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/13/2020] [Accepted: 10/21/2020] [Indexed: 12/14/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Carson M. Quinn
- School of Medicine, University of California, San Francisco, CA 94143, USA
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; (J.K.); (J.G.); (F.V.C.)
| | - Victoria Poplin
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, KS 66045, USA; (V.P.); (N.C.B.)
| | - John Kasibante
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; (J.K.); (J.G.); (F.V.C.)
| | - Kyle Yuquimpo
- Department of Medicine, University of Kansas, Kansas City, KS 66045, USA;
| | - Jane Gakuru
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; (J.K.); (J.G.); (F.V.C.)
| | - Fiona V. Cresswell
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; (J.K.); (J.G.); (F.V.C.)
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Medical Research Council, Uganda Virus Research Unit, London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Nathan C. Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, KS 66045, USA; (V.P.); (N.C.B.)
| |
Collapse
|
4
|
Sharan R, Bucşan AN, Ganatra S, Paiardini M, Mohan M, Mehra S, Khader SA, Kaushal D. Chronic Immune Activation in TB/HIV Co-infection. Trends Microbiol 2020; 28:619-632. [PMID: 32417227 PMCID: PMC7390597 DOI: 10.1016/j.tim.2020.03.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/03/2020] [Accepted: 03/25/2020] [Indexed: 12/27/2022]
Abstract
HIV co-infection is the most critical risk factor for the reactivation of latent tuberculosis (TB) infection (LTBI). While CD4+ T cell depletion has been considered the major cause of HIV-induced reactivation of LTBI, recent work in macaques co-infected with Mycobacterium tuberculosis (Mtb)/simian immunodeficiency virus (SIV) suggests that cytopathic effects of SIV resulting in chronic immune activation and dysregulation of T cell homeostasis correlate with reactivation of LTBI. This review builds on compelling data that the reactivation of LTBI during HIV co-infection is likely to be driven by the events of HIV replication and therefore highlights the need to have optimum translational interventions directed at reactivation due to co-infection.
Collapse
Affiliation(s)
- Riti Sharan
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, TX 78227, USA
| | - Allison N Bucşan
- Department of Microbiology and Immunology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Shashank Ganatra
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, TX 78227, USA
| | - Mirko Paiardini
- Yerkes National Primate Research Center, Emory University School of Medicine, Atlanta, GA 30329, USA
| | - Mahesh Mohan
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, TX 78227, USA
| | - Smriti Mehra
- Tulane National Primate Research Center, Tulane University School of Medicine, Covington, LA 70433, USA
| | - Shabaana A Khader
- Department of Molecular Microbiology, Washington University in St Louis School of Medicine, St Louis, MO 63110, USA
| | - Deepak Kaushal
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, TX 78227, USA.
| |
Collapse
|
5
|
de Sá NBR, Ribeiro-Alves M, da Silva TP, Pilotto JH, Rolla VC, Giacoia-Gripp CBW, Scott-Algara D, Morgado MG, Teixeira SLM. Clinical and genetic markers associated with tuberculosis, HIV-1 infection, and TB/HIV-immune reconstitution inflammatory syndrome outcomes. BMC Infect Dis 2020; 20:59. [PMID: 31959123 PMCID: PMC6971853 DOI: 10.1186/s12879-020-4786-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 01/09/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) and AIDS are the leading causes of infectious disease death worldwide. In some TB-HIV co-infected individuals treated for both diseases simultaneously, a pathological inflammatory reaction termed immune reconstitution inflammatory syndrome (IRIS) may occur. The risk factors for IRIS are not fully defined. We investigated the association of HLA-B, HLA-C, and KIR genotypes with TB, HIV-1 infection, and IRIS onset. METHODS Patients were divided into four groups: Group 1- TB+/HIV+ (n = 88; 11 of them with IRIS), Group 2- HIV+ (n = 24), Group 3- TB+ (n = 24) and Group 4- healthy volunteers (n = 26). Patients were followed up at INI/FIOCRUZ and HGNI (Rio de Janeiro/Brazil) from 2006 to 2016. The HLA-B and HLA-C loci were typed using SBT, NGS, and KIR genes by PCR-SSP. Unconditional logistic regression models were performed for Protection/risk estimation. RESULTS Among the individuals with TB as the outcome, KIR2DS2 was associated with increased risk for TB onset (aOR = 2.39, P = 0.04), whereas HLA-B*08 and female gender were associated with protection against TB onset (aOR = 0.23, P = 0.03, and aOR = 0.33, P = 0.01, respectively). Not carrying KIR2DL3 (aOR = 0.18, P = 0.03) and carrying HLA-C*07 (aOR = 0.32, P = 0.04) were associated with protection against TB onset among HIV-infected patients. An increased risk for IRIS onset was associated with having a CD8 count ≤500 cells/mm3 (aOR = 18.23, P = 0.016); carrying the KIR2DS2 gene (aOR = 27.22, P = 0.032), the HLA-B*41 allele (aOR = 68.84, P = 0.033), the KIR2DS1 + HLA-C2 pair (aOR = 28.58, P = 0.024); and not carrying the KIR2DL3 + HLA-C1/C2 pair (aOR = 43.04, P = 0.034), and the KIR2DL1 + HLA-C1/C2 pair (aOR = 43.04, P = 0.034), CONCLUSIONS: These results suggest the participation of these genes in the immunopathogenic mechanisms related to the conditions studied. This is the first study demonstrating an association of HLA-B*41, KIR2DS2, and KIR + HLA-C pairs with IRIS onset among TB-HIV co-infected individuals.
Collapse
Affiliation(s)
- Nathalia Beatriz Ramos de Sá
- Laboratory of AIDS & Molecular Immunology, Oswaldo Cruz Institute, FIOCRUZ. Av. Brasil 4365, Leonidas Deane Building, room 401, Rio de Janeiro, 21040-360, Brazil
| | - Marcelo Ribeiro-Alves
- Laboratory of Clinical Research on STD/AIDS, National Institute of Infectious Diseases Evandro Chagas, FIOCRUZ, Rio de Janeiro, Brazil
| | - Tatiana Pereira da Silva
- Laboratory of AIDS & Molecular Immunology, Oswaldo Cruz Institute, FIOCRUZ. Av. Brasil 4365, Leonidas Deane Building, room 401, Rio de Janeiro, 21040-360, Brazil
| | - Jose Henrique Pilotto
- Laboratory of AIDS & Molecular Immunology, Oswaldo Cruz Institute, FIOCRUZ. Av. Brasil 4365, Leonidas Deane Building, room 401, Rio de Janeiro, 21040-360, Brazil
- Nova Iguaçu General Hospital, Nova Iguaçu, Rio de Janeiro, Brazil
| | - Valeria Cavalcanti Rolla
- Clinical Research Laboratory on Mycobacteria, National Institute of Infectious Diseases Evandro Chagas, FIOCRUZ, Rio de Janeiro, Brazil
| | - Carmem B W Giacoia-Gripp
- Laboratory of AIDS & Molecular Immunology, Oswaldo Cruz Institute, FIOCRUZ. Av. Brasil 4365, Leonidas Deane Building, room 401, Rio de Janeiro, 21040-360, Brazil
| | - Daniel Scott-Algara
- Unité de Biologie Cellulaire des Lymphocytes, Institut Pasteur, Paris, France
| | - Mariza Gonçalves Morgado
- Laboratory of AIDS & Molecular Immunology, Oswaldo Cruz Institute, FIOCRUZ. Av. Brasil 4365, Leonidas Deane Building, room 401, Rio de Janeiro, 21040-360, Brazil.
| | - Sylvia Lopes Maia Teixeira
- Laboratory of AIDS & Molecular Immunology, Oswaldo Cruz Institute, FIOCRUZ. Av. Brasil 4365, Leonidas Deane Building, room 401, Rio de Janeiro, 21040-360, Brazil
| |
Collapse
|
6
|
Cevaal PM, Bekker LG, Hermans S. TB-IRIS pathogenesis and new strategies for intervention: Insights from related inflammatory disorders. Tuberculosis (Edinb) 2019; 118:101863. [PMID: 31561185 DOI: 10.1016/j.tube.2019.101863] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 09/10/2019] [Accepted: 09/12/2019] [Indexed: 12/29/2022]
Abstract
In almost one in five HIV/tuberculosis (TB) co-infected patients, initiation of antiretroviral therapy (ART) is complicated by TB immune reconstitution inflammatory syndrome (TB-IRIS). Corticosteroids have been suggested for treatment of severe cases, however no therapy is currently licensed for TB-IRIS. Hence, there is a strong need for more specific therapeutics, and therefore, a better understanding of TB-IRIS pathogenesis. Immune reconstitution following ART is a precariously balanced functional restoration of adaptive immunity. In those patients predisposed to disease, an incomplete activation of the innate immune system leads to a hyper-inflammatory response that comprises partially overlapping innate, adaptive and effector arms, eventually leading to clinical symptoms. Interestingly, many of these pathological mechanisms are shared by related inflammatory disorders. We here describe therapeutic strategies that originate from these other disciplines and discuss their potential application in TB-IRIS. These new avenues of interventions range from final-phase treatment of symptoms to early-phase prevention of disease onset. In conclusion, we propose a novel approach for the discovery and development of therapeutics, based on an updated model of TB-IRIS pathogenesis. Further experimental studies validating the causal relationships in the proposed model could greatly contribute to providing a solid immunological basis for future clinical trials on TB-IRIS therapeutics.
Collapse
Affiliation(s)
- Paula M Cevaal
- Amsterdam UMC, University of Amsterdam, Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam Public Health Research Institute, Paasheuvelweg 25, 1105, BP Amsterdam, the Netherlands.
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Anzio Rd, Observatory, 7925, Cape Town, South Africa
| | - Sabine Hermans
- Amsterdam UMC, University of Amsterdam, Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam Public Health Research Institute, Paasheuvelweg 25, 1105, BP Amsterdam, the Netherlands; Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Anzio Rd, Observatory, 7925, Cape Town, South Africa
| |
Collapse
|
7
|
The tuberculosis-associated immune reconstitution inflammatory syndrome: recent advances in clinical and pathogenesis research. Curr Opin HIV AIDS 2019; 13:512-521. [PMID: 30124473 PMCID: PMC6181275 DOI: 10.1097/coh.0000000000000502] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Purpose of review Antiretroviral therapy (ART) is an essential, life-saving intervention for HIV infection. However, ART initiation is frequently complicated by the tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) in TB endemic settings. Here, we summarize the current understanding highlighting the recent evidence. Recent findings The incidence of paradoxical TB-IRIS is estimated at 18% (95% CI 16–21%), higher than previously reported and may be over 50% in high-risk groups. Early ART initiation in TB patients increases TB-IRIS risk by greater than two-fold, but is critical in TB patients with CD4 counts less than 50 cells/μl because it improves survival. There remains no validated diagnostic test for TB-IRIS, and biomarkers recently proposed are not routinely used. Prednisone initiated alongside ART in selected patients with CD4 less than 100 cells/μl reduced the risk of paradoxical TB-IRIS by 30% in a recent randomized-controlled trial (RCT) and was not associated with significant adverse effects. Effective also for treating paradoxical TB-IRIS, corticosteroids remain the only therapeutic intervention for TB-IRIS supported by RCT trial data. TB-IRIS pathogenesis studies implicate high antigen burden, innate immune cell cytotoxicity, inflammasome activation and dysregulated matrix metalloproteinases in the development of the condition. Summary Specific biomarkers would aid in identifying high-risk patients for interventions and a diagnostic test is needed. Clinicians should consider prednisone for TB-IRIS prevention in selected patients. Future research should focus on improving diagnosis and investigating novel therapeutic interventions, especially for patients in whom corticosteroid therapy is contraindicated.
Collapse
|
8
|
Narendran G, Oliveira-de-Souza D, Vinhaes CL, Akrami K, Fukutani KF, Banu K, Chandrasekaran P, Ravichandran N, Sereti I, Swaminathan S, Andrade BB. Multifocal tuberculosis-associated immune reconstitution inflammatory syndrome - a case report of a complicated scenario. BMC Infect Dis 2019; 19:529. [PMID: 31208430 PMCID: PMC6580602 DOI: 10.1186/s12879-019-4182-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 06/11/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tuberculosis (TB)-associated Immune reconstitution inflammatory syndrome (TB-IRIS) is an aberrant inflammatory response in TB patients with advanced human immunodeficiency virus coinfection, after antiretroviral therapy commencement. CASE PRESENTATION We present a rare case of a 51-year-old woman living with HIV who developed a series of TB-IRIS events occurring at multiple sites sequentially, highlighting the clinical complexity in diagnosis and management. CONCLUSION This case illustrates how complicated a clinical scenario of successive TB-IRIS episodes can be, in terms of clinical management.
Collapse
Affiliation(s)
- Gopalan Narendran
- National Institute for Research in Tuberculosis, Chennai, 600031, India
| | - Deivide Oliveira-de-Souza
- Instituto GonçaloMoniz, Fundação Oswaldo Cruz, Salvador, 40296-710, Brazil.,Multinational Organization Network SponsoringTranslationaland Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, 40210-320, Brazil.,Curso de Medicina, Faculdade de Tecnologia e Ciências (FTC), Salvador, 40290-150, Brazil
| | - Caian L Vinhaes
- Instituto GonçaloMoniz, Fundação Oswaldo Cruz, Salvador, 40296-710, Brazil.,Multinational Organization Network SponsoringTranslationaland Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, 40210-320, Brazil.,Curso de Medicina, Faculdade de Tecnologia e Ciências (FTC), Salvador, 40290-150, Brazil
| | - Kevan Akrami
- Instituto GonçaloMoniz, Fundação Oswaldo Cruz, Salvador, 40296-710, Brazil.,Division of Infectious Diseases, Department of Medicine, University of California, San Diego, USA
| | - Kiyoshi F Fukutani
- Instituto GonçaloMoniz, Fundação Oswaldo Cruz, Salvador, 40296-710, Brazil.,Multinational Organization Network SponsoringTranslationaland Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, 40210-320, Brazil.,Curso de Medicina, Faculdade de Tecnologia e Ciências (FTC), Salvador, 40290-150, Brazil
| | | | | | | | - Irini Sereti
- National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | | | - Bruno B Andrade
- Instituto GonçaloMoniz, Fundação Oswaldo Cruz, Salvador, 40296-710, Brazil. .,Multinational Organization Network SponsoringTranslationaland Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, 40210-320, Brazil. .,Curso de Medicina, Faculdade de Tecnologia e Ciências (FTC), Salvador, 40290-150, Brazil. .,Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, 7925, South Africa. .,Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, 37232, USA. .,Universidade Salvador (UNIFACS), Laureate Universities, Salvador, 41720-200, Brazil. .,Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, 40290-000, Brazil.
| |
Collapse
|
9
|
Goovaerts O, Massinga-Loembé M, Ondoa P, Ceulemans A, Worodria W, Mayanja-Kizza H, Colebunders R, Kestens L. Increased KLRG1 and PD-1 expression on CD8 T lymphocytes in TB-IRIS. PLoS One 2019; 14:e0215991. [PMID: 31022273 PMCID: PMC6483230 DOI: 10.1371/journal.pone.0215991] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 04/11/2019] [Indexed: 12/23/2022] Open
Abstract
Background Tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is an inflammatory complication in HIV-TB co-infected patients receiving antiretroviral therapy (ART). The exact contribution of T cells, natural killer (NK) cells, and monocytes to TB-IRIS development remains unclear. Here, we studied the expression of exhaustion markers on lymphocytes at different intervals during ART. Methods We compared 13 HIV-TB patients who developed TB-IRIS with 13 patients who did not (HIV+TB+), 13 HIV-patients without TB (HIV+TB-) and 9 HIV/TB-negative controls (HIV-TB-). Patients did not differ in age, gender, or CD4-count prior to ART. Frozen peripheral blood mononuclear cells, collected before ART and during 3 months and 9 months of ART, were analysed using flow cytometry. We examined expression of KLRG1, PD-1 and IL-27R on CD4+ and CD8hi T cells, as well as CD3-negative CD8lo lymphocytes as an approximate subset of NK cells. In addition, expression of TLR2, TLR4, IL1RL1, and TRAILR on CD14+ monocytes were investigated. Results Prior to ART, TB-IRIS patients had higher percentages of CD8hi T cells that are KLRG1+PD-1+ compared to each control group (p≤0.034). Though PD-1 expression decreased during ART in all groups (p≤0.026), the percentage KLRG1+PD-1+CD8hi T cells remained higher in TB-IRIS patients after 3 months of ART (p≤0.013). Though these patterns were less pronounced in CD3-CD8lo lymphocytes, the percentage of KLRG1+ cells was higher in TB-IRIS patients prior to ART (p≤0.043). In contrast, no clear differences could be observed for CD4+ T cells or monocytes. Conclusion TB-IRIS is preceded by a high level of exhausted (KLRG1+PD-1+) CD8hi T cells, which persists during 3 months of ART. This trait is potentially mirrored in a subpopulation of NK cells, but not CD4+ T cells. Since a dysfunctional CD8+ lymphocyte compartment could predispose patients to TB-IRIS, the functional role of these cells prior to TB-IRIS development should be further explored.
Collapse
Affiliation(s)
- Odin Goovaerts
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- * E-mail:
| | - Marguerite Massinga-Loembé
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Centre de Recherches Médicales de Lambaréné (CERMEL), Albert Schweitzer Hospital, Lambarene, Gabon
- Institut für Tropenmedizin, Universität Tübingen, Tübingen, Germany
| | - Pascale Ondoa
- Department of Global Health and Amsterdam Institute for Global Health and Development, Academic Medical Centre, Amsterdam, The Netherlands
| | - Ann Ceulemans
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - William Worodria
- Department of Medicine, Mulago Hospital, Kampala, Uganda
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Infectious Diseases Network for Treatment and Research in Africa (INTERACT), Kampala, Uganda
| | - Harriet Mayanja-Kizza
- Department of Medicine, Mulago Hospital, Kampala, Uganda
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Robert Colebunders
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Luc Kestens
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | | |
Collapse
|
10
|
Silveira-Mattos PS, Narendran G, Akrami K, Fukutani KF, Anbalagan S, Nayak K, Subramanyam S, Subramani R, Vinhaes CL, Souza DOD, Antonelli LR, Satagopan K, Porter BO, Sher A, Swaminathan S, Sereti I, Andrade BB. Differential expression of CXCR3 and CCR6 on CD4 + T-lymphocytes with distinct memory phenotypes characterizes tuberculosis-associated immune reconstitution inflammatory syndrome. Sci Rep 2019; 9:1502. [PMID: 30728405 PMCID: PMC6365576 DOI: 10.1038/s41598-018-37846-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 12/12/2018] [Indexed: 11/09/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) occurs in up to 40% of individuals co-infected with pulmonary tuberculosis (PTB) and HIV, primarily upon antiretroviral therapy (ART) initiation. Phenotypic changes in T-cells during TB-IRIS and their relationship with systemic inflammation are not fully understood. In this prospective cohort study, we followed 48 HIV-positive patients with PTB from South India before and after ART initiation, examining T-lymphocyte subsets and inflammatory biomarkers in peripheral blood. Quantification of naïve (CD27+CD45RO-) as well as effector memory CD4+ T cells (CD27-CD45RO+) at weeks 2-6 after ART initiation could distinguish TB-IRIS from non-IRIS individuals. Additional analyses revealed that ART reconstituted different quantities of CD4+ T lymphocyte subsets with preferential expansion of CXCR3+ CCR6- cells in TB-IRIS patients. Moreover, there was an expansion and functional restoration of central memory (CD27+CD45RO+) CXCR3+CCR6- CD4+ lymphocytes and corresponding cytokines, with reduction in CXCR3-CCR6+ cells after ART initiation only in those who developed TB-IRIS. Together, these observations trace a detailed picture of CD4+ T cell subsets tightly associated with IRIS, which may serve as targets for prophylactic and/or therapeutic interventions in the future.
Collapse
Affiliation(s)
- Paulo S Silveira-Mattos
- Instituto Gonçalo Moniz, Salvador, Bahia, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, Bahia, Brazil
| | | | - Kevan Akrami
- Instituto Gonçalo Moniz, Salvador, Bahia, Brazil.,Division of Infectious Diseases, Department of Medicine, University of California, San Diego, United States of America
| | - Kiyoshi F Fukutani
- Instituto Gonçalo Moniz, Salvador, Bahia, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, Bahia, Brazil
| | | | - Kaustuv Nayak
- National Institute for Research in Tuberculosis, Chennai, India
| | | | | | - Caian L Vinhaes
- Instituto Gonçalo Moniz, Salvador, Bahia, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, Bahia, Brazil
| | - Deivide Oliveira-de Souza
- Instituto Gonçalo Moniz, Salvador, Bahia, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, Bahia, Brazil
| | - Lis R Antonelli
- Laboratório de Biologia e Imunologia de Doenças Infecciosas e Parasitárias, Instituto René Rachou, Fundação Oswaldo Cruz, Belo Horizonte, Minas Gerais, Brazil
| | - Kumar Satagopan
- Government Hospital of Thoracic Medicine, Tambaram, Chennai, India
| | - Brian O Porter
- Clinical HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Alan Sher
- Immunobiology Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | | | - Irini Sereti
- Clinical HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Bruno B Andrade
- Instituto Gonçalo Moniz, Salvador, Bahia, Brazil. .,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, Bahia, Brazil. .,Wellcome Trust Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, Republic of South Africa. .,Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, Bahia, Brazil. .,Universidade Salvador (UNIFACS), Laureate Universities, Salvador, Bahia, Brazil. .,Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America.
| |
Collapse
|
11
|
Esmail H, Riou C, Bruyn ED, Lai RPJ, Harley YXR, Meintjes G, Wilkinson KA, Wilkinson RJ. The Immune Response to Mycobacterium tuberculosis in HIV-1-Coinfected Persons. Annu Rev Immunol 2018; 36:603-638. [PMID: 29490165 DOI: 10.1146/annurev-immunol-042617-053420] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Globally, about 36.7 million people were living with HIV infection at the end of 2015. The most frequent infection co-occurring with HIV-1 is Mycobacterium tuberculosis-374,000 deaths per annum are attributable to HIV-tuberculosis, 75% of those occurring in Africa. HIV-1 infection increases the risk of tuberculosis by a factor of up to 26 and alters its clinical presentation, complicates diagnosis and treatment, and worsens outcome. Although HIV-1-induced depletion of CD4+ T cells underlies all these effects, more widespread immune deficits also contribute to susceptibility and pathogenesis. These defects present a challenge to understand and ameliorate, but also an opportunity to learn and optimize mechanisms that normally protect people against tuberculosis. The most effective means to prevent and ameliorate tuberculosis in HIV-1-infected people is antiretroviral therapy, but this may be complicated by pathological immune deterioration that in turn requires more effective host-directed anti-inflammatory therapies to be derived.
Collapse
Affiliation(s)
- Hanif Esmail
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town 7925, Republic of South Africa; .,Department of Medicine, Imperial College London, London W2 1PG, United Kingdom.,Radcliffe Department of Medicine, University of Oxford, Oxford OX3 9DU, United Kingdom
| | - Catherine Riou
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town 7925, Republic of South Africa;
| | - Elsa du Bruyn
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town 7925, Republic of South Africa;
| | | | - Yolande X R Harley
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town 7925, Republic of South Africa;
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town 7925, Republic of South Africa;
| | - Katalin A Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town 7925, Republic of South Africa; .,The Francis Crick Institute, London NW1 2AT, United Kingdom
| | - Robert J Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town 7925, Republic of South Africa; .,Department of Medicine, Imperial College London, London W2 1PG, United Kingdom.,The Francis Crick Institute, London NW1 2AT, United Kingdom
| |
Collapse
|
12
|
Nakiwala JK, Walker NF, Diedrich CR, Worodria W, Meintjes G, Wilkinson RJ, Mayanja-Kizza H, Colebunders R, Kestens L, Wilkinson KA, Lowe DM. Neutrophil Activation and Enhanced Release of Granule Products in HIV-TB Immune Reconstitution Inflammatory Syndrome. J Acquir Immune Defic Syndr 2018; 77:221-229. [PMID: 29135655 PMCID: PMC5765966 DOI: 10.1097/qai.0000000000001582] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Tuberculosis immune reconstitution inflammatory syndrome (TB-IRIS) remains incompletely understood. Neutrophils are implicated in tuberculosis pathology but detailed investigations in TB-IRIS are lacking. We sought to further explore the biology of TB-IRIS and, in particular, the role of neutrophils. SETTING Two observational, prospective cohort studies in HIV/TB coinfected patients starting antiretroviral therapy (ART), 1 to analyze gene expression and subsequently 1 to explore neutrophil biology. METHODS nCounter gene expression analysis was performed in patients with TB-IRIS (n = 17) versus antiretroviral-treated HIV/TB coinfected controls without IRIS (n = 17) in Kampala, Uganda. Flow cytometry was performed in patients with TB-IRIS (n = 18) and controls (n = 11) in Cape Town, South Africa to determine expression of neutrophil surface activation markers, intracellular cytokines, and human neutrophil peptides (HNPs). Plasma neutrophil elastase and HNP1-3 were quantified using enzyme-linked immunosorbent assay. Lymph node immunohistochemistry was performed on 3 further patients with TB-IRIS. RESULTS There was a significant increase in gene expression of S100A9 (P = 0.002), NLRP12 (P = 0.018), COX-1 (P = 0.025), and IL-10 (P = 0.045) 2 weeks after ART initiation in Ugandan patients with TB-IRIS versus controls, implicating neutrophil recruitment. Patients with IRIS in both cohorts demonstrated increases in blood neutrophil count, plasma HNP and elastase concentrations from ART initiation to week 2. CD62L (L-selectin) expression on neutrophils increased over 4 weeks in South African controls whereas patients with IRIS demonstrated the opposite. Intense staining for the neutrophil marker CD15 and IL-10 was seen in necrotic areas of the lymph nodes of the patients with TB-IRIS. CONCLUSIONS Neutrophils in TB-IRIS are activated, recruited to sites of disease, and release granule contents, contributing to pathology.
Collapse
Affiliation(s)
- Justine K Nakiwala
- Department of Medicine, Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
| | - Naomi F Walker
- Department of Medicine, Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Collin R Diedrich
- Department of Medicine, Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
- Pediatrics, Division of Infectious Disease, Children's Hospital of UPMC, University of Pittsburgh, Pittsburgh, PA
| | - William Worodria
- Department of Medicine, Mulago Hospital, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Graeme Meintjes
- Department of Medicine, Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
- Department of Medicine, Imperial College London, London, United Kingdom
| | - Robert J Wilkinson
- Department of Medicine, Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
- Department of Medicine, Imperial College London, London, United Kingdom
- The Francis Crick Institute, London, United Kingdom
| | - Harriet Mayanja-Kizza
- Department of Medicine, Mulago Hospital, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Robert Colebunders
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Luc Kestens
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
| | - Katalin A Wilkinson
- Department of Medicine, Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
- The Francis Crick Institute, London, United Kingdom
| | - David M Lowe
- Department of Medicine, Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
- Department of Medicine, Imperial College London, London, United Kingdom
- Institute of Immunity and Transplantation, University College London, London, United Kingdom
| |
Collapse
|
13
|
Fu Y, Xu X, Xue J, Duan W, Yi Z. Deregulated lncRNAs in B Cells from Patients with Active Tuberculosis. PLoS One 2017; 12:e0170712. [PMID: 28125665 PMCID: PMC5268381 DOI: 10.1371/journal.pone.0170712] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 01/09/2017] [Indexed: 12/18/2022] Open
Abstract
Role of lncRNAs in human adaptive immune response to TB infection is largely unexplored. To address this issue, here we characterized lncRNA expression profile in primary human B cell response to TB infection using microarray assay. Several lncRNAs and mRNAs were chosen for RT-qPCR validation. Bioinformatics prediction was applied to delineate function of the deregulated mRNAs. We found that 844 lncRNAs and 597 mRNAs were differentially expressed between B cell samples from individuals with or without TB. KEGG pathway analysis for the deregulated mRNAs indicated a number of pathways, such as TB, TLR signaling pathway and antigen processing and presentation. Moreover, corresponding to the dysregulation of many lncRNAs, we also found that their adjacent protein-coding genes were also deregulated. Functional annotation for the corresponding mRNAs showed that these lncRNAs were mainly associated with TLR signaling, TGF-β signaling. Interestingly, SOCS3, which is a critical negative regulator of cytokine response to TB infection and its nearby lncRNA XLOC_012582, were highly expressed in active TB B cells. Subsequent RT-qPCR results confirmed the changes. Whether upregulated XLOC_012582 causes SOCS3 overexpression and is eventually involved in the context of exacerbations of active TB represents an interesting issue that deserves to be further explored. Taken together, for the first time, we identified a set of deregulated lncRNAs in active TB B cells and their functions were predicted. Such findings provided novel insight into the pathogenesis of TB and further studies should focus on the function and pathogenic mechanisms of the lncRNAs involved in active TB.
Collapse
Affiliation(s)
- Yurong Fu
- Department of Medical Microbiology of Clinical Medicine College, Weifang Medical University, Shandong, Weifang, China
- Department of Laboratory Medicine, Key Laboratory of Clinical Laboratory Diagnostics in Universities of Shandong, Weifang Medical University, Shandong, Weifang, China
- * E-mail: (YF); (ZY)
| | - Xianqin Xu
- Department of Clinical Skill Laboratory of Clinical Medicine College, Weifang Medical University, Shandong, Weifang, China
| | - Junfang Xue
- Department of Surgery of Gaomi City people's Hospital, Shandong, Weifang, China
| | - Wenping Duan
- Department of Nursing of Affiliated Hospital of Weifang Medical University, Shandong, Weifang, China
| | - Zhengjun Yi
- Department of Laboratory Medicine, Key Laboratory of Clinical Laboratory Diagnostics in Universities of Shandong, Weifang Medical University, Shandong, Weifang, China
- * E-mail: (YF); (ZY)
| |
Collapse
|
14
|
Abstract
PURPOSE OF REVIEW This article explores new data from recent studies addressing the role of coinfections in immune activation in HIV-1-infected patients, with a focus on immune reconstitution inflammatory syndrome (IRIS), an aberrant inflammatory response occurring shortly after antiretroviral therapy (ART) initiation. RECENT FINDINGS Chronic HIV infection is associated with several coinfections that contribute to immune activation in various settings including early after ART initiation in the most noticeable form of IRIS and also in chronic-treated infection, with chronic viral infections like cytomegalovirus and hepatitis C or hepatitis B virus contributing to immune activation and also morbidity and mortality. Expanding on older studies, the role of T cells in IRIS has been further elucidated with evidence of more pronounced effector activity in patients with IRIS that may be leading to excessive tissue disorder. Newer studies are also continuing to shed light on the role of myeloid cells as well as the contribution of antigen load in IRIS. In addition, preliminary data are beginning to suggest a possible role of inflammasome formation in IRIS. In cryptococcal IRIS, the role of activated immune cells (T cell and myeloid) and biomarkers were evaluated in more detail at the site of infection (cerebrospinal fluid). Finally, important differences of patients developing IRIS versus those who die from tuberculosis despite ART initiation were reported, a distinction that may have important implications for participant selection in studies aiming to prevent IRIS with immunosuppressive agents. SUMMARY Better understanding of the role of opportunistic infections at ART initiation and IRIS pathogenesis will assist in improved strategies for prevention and treatment. The long-term consequences of IRIS remain unclear. Chronic viral coinfections with herpesviruses and hepatitis C virus are important factors in persistent immune activation in chronic-treated HIV.
Collapse
|
15
|
Ravimohan S, Tamuhla N, Nfanyana K, Steenhoff AP, Letlhogile R, Frank I, MacGregor RR, Gross R, Weissman D, Bisson GP. Robust Reconstitution of Tuberculosis-Specific Polyfunctional CD4+ T-Cell Responses and Rising Systemic Interleukin 6 in Paradoxical Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome. Clin Infect Dis 2015; 62:795-803. [PMID: 26611774 DOI: 10.1093/cid/civ978] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Accepted: 11/17/2015] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The immunopathogenesis of paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) remains unclear. We determined the association between pathogen-specific T-cell responses and development of paradoxical TB-IRIS on antiretroviral therapy (ART). METHODS This study was nested within a prospective cohort study of HIV-infected patients with active pulmonary tuberculosis and baseline CD4 counts ≤125 cells/µL initiating ART. T-cell immune activation (CD38, HLA-DR, and PD-1 expression), phenotype, and polyfunctional pathogen-specific cellular immune responses prior to and 4 weeks after ART initiation were determined by flow cytometry. Patients with TB-IRIS were compared to non-IRIS controls using χ(2) and rank-sum tests and logistic regression. RESULTS TB-IRIS patients and controls had similar CD4 counts, levels of T-cell-associated immune activation, frequencies of T-cell memory subsets, and frequencies of interferon gamma (IFN-γ(+))/interleukin 2 (IL-2(+))/tumor necrosis factor alpha (TNF-α(+)) CD4(+) T-cells prior to ART initiation. After ART initiation, cellular immune activation and T-cell subsets also were similar in TB-IRIS patients and controls. In contrast, TB-IRIS patients had significantly greater early increases in the frequency of tuberculosis-specific polyfunctional IFN-γ(+)/IL-2(+)/TNF-α(+) CD4(+) T-cells on ART (P = .02); each quartile increase in the percentage of these cells was independently associated with a 2.8-fold increased risk of TB-IRIS (95% confidence interval, 1.1 to 7.5-fold). In a secondary analysis, patients with TB-IRIS had rapid, concomitant increases in tuberculosis-specific adaptive immune responses and interleukin 6 (IL-6) levels, whereas controls with similarly rapid increases in cellular immune function had IL-6 levels that tended to decrease on ART. CONCLUSIONS Rapid expansion of tuberculosis-specific polyfunctional CD4(+) T-cell responses, likely linked to increases in IL-6, is associated with development of paradoxical TB-IRIS.
Collapse
Affiliation(s)
- Shruthi Ravimohan
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Botswana-UPenn Partnership, Gaborone
| | | | | | - Andrew P Steenhoff
- Botswana-UPenn Partnership, Gaborone.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania.,Children's Hospital of Philadelphia
| | | | - Ian Frank
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Rob Roy MacGregor
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Robert Gross
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Botswana-UPenn Partnership, Gaborone.,Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Drew Weissman
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Botswana-UPenn Partnership, Gaborone
| | - Gregory P Bisson
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Botswana-UPenn Partnership, Gaborone.,Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| |
Collapse
|
16
|
Ravimohan S, Bisson GP. To have and have not: dissecting protective and pathologic immune recovery in TB-IRIS. Future Virol 2015. [DOI: 10.2217/fvl.15.91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is a growing concern for advanced HIV/TB coinfected patients in an era where antiretroviral therapy (ART) is started shortly after TB treatment initiation. This perspective discusses potential mechanisms underlying TB-IRIS, focusing on recent studies that implicate coordinated recovery in adaptive and innate immune responses following ART initiation in TB-IRIS. More broadly, HIV/TB patients are probably a heterogeneous group whose outcomes are determined by the direction in which these immune responses change following ART initiation. Finally, in addition to treatment interventions that are in the pipeline for TB-IRIS, we highlight the need for holistic management of HIV/TB coinfected patients, which go beyond the current definition of TB-IRIS and take into consideration long-term consequences of robust immune recovery on ART.
Collapse
Affiliation(s)
- Shruthi Ravimohan
- Perelman School of Medicine at the University of Pennsylvania, Department of Medicine, Division of Infectious Diseases, 502 Johnson Pavilion, 3610 Hamilton Walk, Philadelphia, PA 19104-60732, USA
- Botswana–UPenn Partnership, University of Botswana, Main Campus, 244G – Room 103, Gaborone, Botswana
| | - Gregory P Bisson
- Perelman School of Medicine at the University of Pennsylvania, Department of Medicine, Division of Infectious Diseases, 502 Johnson Pavilion, 3610 Hamilton Walk, Philadelphia, PA 19104-60732, USA
- Botswana–UPenn Partnership, University of Botswana, Main Campus, 244G – Room 103, Gaborone, Botswana
- Perelman School of Medicine at the University of Pennsylvania, Department of Biostatistics & Epidemiology, Center for Clinical Epidemiology & Biostatistics, Philadelphia, PA 19104, USA
| |
Collapse
|