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Lemos CX, Anton C, Machado FD, Bernardi RM, Freitas AA, Silva DR. Adjunctive corticosteroid therapy in patients with pulmonary tuberculosis. Rev Assoc Med Bras (1992) 2022; 68:1199-1203. [PMID: 36228251 PMCID: PMC9575022 DOI: 10.1590/1806-9282.20220196] [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: 05/10/2022] [Accepted: 05/23/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES In tuberculosis treatment, corticosteroids are used as adjuvants, especially in meningeal/pericardial tuberculosis. In other forms of the disease, especially in severe tuberculosis requiring mechanical ventilation, its use is controversial. The aim of the present study is to assess whether the use of corticosteroids in the treatment of pulmonary tuberculosis patients in mechanical ventilation is associated with in-hospital mortality. METHODS This is a retrospective cohort study. Tuberculosis patients >18 years requiring mechanical ventilation, admitted to the emergency department or intensive care unit, were included. Data on corticosteroid use and mortality were collected. RESULTS In total, 467 patients were included in the analysis; 399 used corticosteroids and 68 were noncorticosteroid users. The mortality rate was higher among corticosteroid users (59.9%) than in noncorticosteroid users (41.2%) (p=0.010). The total dose of corticosteroid in prednisone equivalents was not different between survivors and nonsurvivors (median [interquartile range]: 80 mg [5-56.6 mg] vs. 80 mg [50-135 mg]; p=0.881). CONCLUSIONS Tuberculosis patients in mechanical ventilation who used corticosteroids had a higher mortality rate than those who did not use corticosteroids. The role of corticosteroids in pulmonary tuberculosis, especially in critically ill patients, remains unclear and needs further evaluation in prospective studies.
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Affiliation(s)
- Carolina Xavier Lemos
- Universidade Federal do Rio Grande do Sul, Graduate Program in Pulmonology Sciences – Porto Alegre (RS), Brazil
| | - Camila Anton
- Universidade Federal do Rio Grande do Sul, Graduate Program in Pulmonology Sciences – Porto Alegre (RS), Brazil
| | - Felipe Dominguez Machado
- Universidade Federal do Rio Grande do Sul, Graduate Program in Pulmonology Sciences – Porto Alegre (RS), Brazil
| | - Rafaela Manzoni Bernardi
- Universidade Federal do Rio Grande do Sul, Graduate Program in Pulmonology Sciences – Porto Alegre (RS), Brazil
| | - Alana Ambos Freitas
- Universidade Federal do Rio Grande do Sul, School of Medicine – Porto Alegre (RS), Brazil
| | - Denise Rossato Silva
- Universidade Federal do Rio Grande do Sul, Graduate Program in Pulmonology Sciences – Porto Alegre (RS), Brazil.,Universidade Federal do Rio Grande do Sul, School of Medicine – Porto Alegre (RS), Brazil.,Hospital de Clínicas de Porto Alegre, Department of Pulmonology – Porto Alegre (RS), Brazil.,Corresponding author:
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2
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Roca FJ, Whitworth LJ, Prag HA, Murphy MP, Ramakrishnan L. Tumor necrosis factor induces pathogenic mitochondrial ROS in tuberculosis through reverse electron transport. Science 2022; 376:eabh2841. [PMID: 35737799 PMCID: PMC7612974 DOI: 10.1126/science.abh2841] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Tumor necrosis factor (TNF) is a critical host resistance factor against tuberculosis. However, excess TNF produces susceptibility by increasing mitochondrial reactive oxygen species (mROS), which initiate a signaling cascade to cause pathogenic necrosis of mycobacterium-infected macrophages. In zebrafish, we identified the mechanism of TNF-induced mROS in tuberculosis. Excess TNF in mycobacterium-infected macrophages elevates mROS production by reverse electron transport (RET) through complex I. TNF-activated cellular glutamine uptake leads to an increased concentration of succinate, a Krebs cycle intermediate. Oxidation of this elevated succinate by complex II drives RET, thereby generating the mROS superoxide at complex I. The complex I inhibitor metformin, a widely used antidiabetic drug, prevents TNF-induced mROS and necrosis of Mycobacterium tuberculosis-infected zebrafish and human macrophages; metformin may therefore be useful in tuberculosis therapy.
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Affiliation(s)
- Francisco J. Roca
- Molecular Immunity Unit, Cambridge Institute of Therapeutic Immunology and Infectious Diseases, Department of Medicine, University of Cambridge, Cambridge CB2 0AW, UK
- Current affiliation: Department of Biochemistry and Molecular Biology B and Immunology, Biomedical Research Institute of Murcia (IMIB-Arrixaca), University of Murcia, Murcia 30120, Spain
| | - Laura J. Whitworth
- Molecular Immunity Unit, Cambridge Institute of Therapeutic Immunology and Infectious Diseases, Department of Medicine, University of Cambridge, Cambridge CB2 0AW, UK
- MRC Laboratory of Molecular Biology, Cambridge CB2 0QH, UK
| | - Hiran A. Prag
- MRC Mitochondrial Biology Unit, University of Cambridge, Cambridge CB2 0XY, UK
| | - Michael P. Murphy
- Molecular Immunity Unit, Cambridge Institute of Therapeutic Immunology and Infectious Diseases, Department of Medicine, University of Cambridge, Cambridge CB2 0AW, UK
- MRC Mitochondrial Biology Unit, University of Cambridge, Cambridge CB2 0XY, UK
| | - Lalita Ramakrishnan
- Molecular Immunity Unit, Cambridge Institute of Therapeutic Immunology and Infectious Diseases, Department of Medicine, University of Cambridge, Cambridge CB2 0AW, UK
- MRC Laboratory of Molecular Biology, Cambridge CB2 0QH, UK
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3
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Xie Y, Xie J, Meijer AH, Schaaf MJM. Glucocorticoid-Induced Exacerbation of Mycobacterial Infection Is Associated With a Reduced Phagocytic Capacity of Macrophages. Front Immunol 2021; 12:618569. [PMID: 34046029 PMCID: PMC8148013 DOI: 10.3389/fimmu.2021.618569] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 04/13/2021] [Indexed: 01/20/2023] Open
Abstract
Glucocorticoids are effective drugs for treating immune-related diseases, but prolonged therapy is associated with an increased risk of various infectious diseases, including tuberculosis. In this study, we have used a larval zebrafish model for tuberculosis, based on Mycobacterium marinum (Mm) infection, to study the effect of glucocorticoids. Our results show that the synthetic glucocorticoid beclomethasone increases the bacterial burden and the dissemination of a systemic Mm infection. The exacerbated Mm infection was associated with a decreased phagocytic activity of macrophages, higher percentages of extracellular bacteria, and a reduced rate of infected cell death, whereas the bactericidal capacity of the macrophages was not affected. The inhibited phagocytic capacity of macrophages was associated with suppression of the transcription of genes involved in phagocytosis in these cells. The decreased bacterial phagocytosis by macrophages was not specific for Mm, since it was also observed upon infection with Salmonella Typhimurium. In conclusion, our results show that glucocorticoids inhibit the phagocytic activity of macrophages, which may increase the severity of bacterial infections like tuberculosis.
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Affiliation(s)
- Yufei Xie
- Institute of Biology, Leiden University, Leiden, Netherlands
| | - Jiajun Xie
- Institute of Biology, Leiden University, Leiden, Netherlands
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4
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Whitworth LJ, Troll R, Pagán AJ, Roca FJ, Edelstein PH, Troll M, Tobin DM, Phu NH, Bang ND, Thwaites GE, Thuong NTT, Sewell RF, Ramakrishnan L. Elevated cerebrospinal fluid cytokine levels in tuberculous meningitis predict survival in response to dexamethasone. Proc Natl Acad Sci U S A 2021; 118:e2024852118. [PMID: 33658385 PMCID: PMC7958233 DOI: 10.1073/pnas.2024852118] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Adjunctive treatment with antiinflammatory corticosteroids like dexamethasone increases survival in tuberculosis meningitis. Dexamethasone responsiveness associates with a C/T variant in Leukotriene A4 Hydrolase (LTA4H), which regulates expression of the proinflammatory mediator leukotriene B4 (LTB4). TT homozygotes, with increased expression of LTA4H, have the highest survival when treated with dexamethasone and the lowest survival without. While the T allele is present in only a minority of the world's population, corticosteroids confer modest survival benefit worldwide. Using Bayesian methods, we examined how pretreatment levels of cerebrospinal fluid proinflammatory cytokines affect survival in dexamethasone-treated tuberculous meningitis. LTA4H TT homozygosity was associated with global cytokine increases, including tumor necrosis factor. Association between higher cytokine levels and survival extended to non-TT patients, suggesting that other genetic variants may also induce dexamethasone-responsive pathological inflammation. These findings warrant studies that tailor dexamethasone therapy to pretreatment cerebrospinal fluid cytokine concentrations, while searching for additional genetic loci shaping the inflammatory milieu.
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Affiliation(s)
- Laura J Whitworth
- Molecular Immunity Unit, Department of Medicine, University of Cambridge, CB2 0QH Cambridge, United Kingdom
- Medical Research Council Laboratory of Molecular Biology, CB2 0QH Cambridge, United Kingdom
| | - Rajan Troll
- Trinity College, CB2 1TQ Cambridge, United Kingdom
| | - Antonio J Pagán
- Molecular Immunity Unit, Department of Medicine, University of Cambridge, CB2 0QH Cambridge, United Kingdom
- Medical Research Council Laboratory of Molecular Biology, CB2 0QH Cambridge, United Kingdom
| | - Francisco J Roca
- Molecular Immunity Unit, Department of Medicine, University of Cambridge, CB2 0QH Cambridge, United Kingdom
- Medical Research Council Laboratory of Molecular Biology, CB2 0QH Cambridge, United Kingdom
| | - Paul H Edelstein
- Molecular Immunity Unit, Department of Medicine, University of Cambridge, CB2 0QH Cambridge, United Kingdom
- Medical Research Council Laboratory of Molecular Biology, CB2 0QH Cambridge, United Kingdom
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - Mark Troll
- Molecular Immunity Unit, Department of Medicine, University of Cambridge, CB2 0QH Cambridge, United Kingdom
- Medical Research Council Laboratory of Molecular Biology, CB2 0QH Cambridge, United Kingdom
| | - David M Tobin
- Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, NC 27710
- Department of Immunology, Duke University School of Medicine, Durham, NC 27710
| | - Nguyen Hoan Phu
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Nguyen Duc Bang
- Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease, Ho Chi Minh City, Vietnam
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, OX3 7BN Oxford, United Kingdom
| | - Nguyen Thuy Thuong Thuong
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, OX3 7BN Oxford, United Kingdom
| | | | - Lalita Ramakrishnan
- Molecular Immunity Unit, Department of Medicine, University of Cambridge, CB2 0QH Cambridge, United Kingdom;
- Medical Research Council Laboratory of Molecular Biology, CB2 0QH Cambridge, United Kingdom
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5
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Ordonez AA, Pokkali S, Kim S, Carr B, Klunk MH, Tong L, Saini V, Chang YS, McKevitt M, Smith V, Gossage DL, Jain SK. Adjunct antibody administration with standard treatment reduces relapse rates in a murine tuberculosis model of necrotic granulomas. PLoS One 2018; 13:e0197474. [PMID: 29758082 PMCID: PMC5951562 DOI: 10.1371/journal.pone.0197474] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 05/02/2018] [Indexed: 01/30/2023] Open
Abstract
Matrix metalloproteinase (MMP)-9 is a zinc-dependent protease associated with early immune responses to Mycobacterium tuberculosis infection, macrophage recruitment and granuloma formation. We evaluated whether adjunctive inhibition of MMP-9 could improve the response to standard TB treatment in a mouse model that develops necrotic lesions. Six weeks after an aerosol infection with M. tuberculosis, C3HeB/FeJ mice received standard TB treatment (12 weeks) comprising rifampin, isoniazid and pyrazinamide alone or in combination with either anti-MMP-9 antibody, etanercept (positive control) or isotype antibody (negative control) for 6 weeks. Anti-MMP-9 and the isotype control had comparable high serum exposures and expected terminal half-life. The relapse rate in mice receiving standard TB treatment was 46.6%. Compared to the standard TB treatment, relapse rates in animals that received adjunctive treatments with anti-MMP-9 antibody or etanercept were significantly decreased to 25.9% (P = 0.006) and 29.8% (P = 0.019) respectively, but were not different from the arm that received the isotype control antibody (25.9%). Immunostaining demonstrated localization of MMP-9 primarily in macrophages in both murine and human lung tissues infected with M. tuberculosis, suggesting the importance of MMP-9 in TB pathogenesis. These data suggest that the relapse rates in M. tuberculosis-infected mice may be non-specifically improved by administration of antibodies in conjunction with standard TB treatments. Future studies are needed to evaluate the mechanism(s) leading to improved outcomes with adjunctive antibody treatments.
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Affiliation(s)
- Alvaro A. Ordonez
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Supriya Pokkali
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Sunhwa Kim
- Gilead Sciences, Inc., Foster City, California, United States of America
| | - Brian Carr
- Gilead Sciences, Inc., Foster City, California, United States of America
| | - Mariah H. Klunk
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Leah Tong
- Gilead Sciences, Inc., Foster City, California, United States of America
| | - Vikram Saini
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Yong S. Chang
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Matthew McKevitt
- Gilead Sciences, Inc., Foster City, California, United States of America
| | - Victoria Smith
- Gilead Sciences, Inc., Foster City, California, United States of America
| | - David L. Gossage
- Gilead Sciences, Inc., Foster City, California, United States of America
| | - Sanjay K. Jain
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
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6
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Kolloli A, Subbian S. Host-Directed Therapeutic Strategies for Tuberculosis. Front Med (Lausanne) 2017; 4:171. [PMID: 29094039 PMCID: PMC5651239 DOI: 10.3389/fmed.2017.00171] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 09/26/2017] [Indexed: 12/18/2022] Open
Abstract
Tuberculosis (TB), caused by Mycobacterium tuberculosis (Mtb), remains a leading cause of morbidity and mortality in humans worldwide. Currently, the standard treatment for TB involves multiple antibiotics administered for at least 6 months. Although multiple antibiotics therapy is necessary to prevent the development of drug resistance, the prolonged duration of treatment, combined with toxicity of drugs, contributes to patient non-compliance that can leads to the development of drug-resistant Mtb (MDR and XDR) strains. The existence of comorbid conditions, including HIV infection, not only complicates TB treatment but also elevates the mortality rate of patients. These facts underscore the need for the development of new and/or improved TB treatment strategies. Host-directed therapy (HDT) is a new and emerging concept in the treatment of TB, where host response is modulated by treatment with small molecules, with or without adjunct antibiotics, to achieve better control of TB. Unlike antibiotics, HDT drugs act by directly modulating host cell functions; therefore, development of drug resistance by infecting Mtb is avoided. Thus, HDT is a promising treatment strategy for the management of MDR- and XDR-TB cases as well as for patients with existing chronic, comorbid conditions such as HIV infection or diabetes. Functionally, HDT drugs fine-tune the antimicrobial activities of host immune cells and limit inflammation and tissue damage associated with TB. However, current knowledge and clinical evidence is insufficient to implement HDT molecules as a stand-alone, without adjunct antibiotics, therapeutic modality to treat any form of TB in humans. In this review, we discuss the recent findings on small molecule HDT agents that target autophagy, vitamin D pathway, and anti-inflammatory response as adjunctive agents along with standard antibiotics for TB therapy. Data from recent publications show that this approach has the potential to improve clinical outcome and can help to reduce treatment duration. Thus, HDT can contribute to global TB control programs by potentially increasing the efficiency of anti-TB treatment.
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Affiliation(s)
- Afsal Kolloli
- Public Health Research Institute (PHRI) at New Jersey Medical School, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, The State University of New Jersey, Newark, NJ, United States
| | - Selvakumar Subbian
- Public Health Research Institute (PHRI) at New Jersey Medical School, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, The State University of New Jersey, Newark, NJ, United States
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7
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Zumla A, Rao M, Dodoo E, Maeurer M. Potential of immunomodulatory agents as adjunct host-directed therapies for multidrug-resistant tuberculosis. BMC Med 2016; 14:89. [PMID: 27301245 PMCID: PMC4908783 DOI: 10.1186/s12916-016-0635-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 06/02/2016] [Indexed: 01/15/2023] Open
Abstract
Treatment of multidrug-resistant tuberculosis (MDR-TB) is extremely challenging due to the virulence of the etiologic strains of Mycobacterium tuberculosis (M. tb), the aberrant host immune responses and the diminishing treatment options with TB drugs. New treatment regimens incorporating therapeutics targeting both M. tb and host factors are urgently needed to improve the clinical management outcomes of MDR-TB. Host-directed therapies (HDT) could avert destructive tuberculous lung pathology, facilitate eradication of M. tb, improve survival and prevent long-term functional disability. In this review we (1) discuss the use of HDT for cancer and other infections, drawing parallels and the precedent they set for MDR-TB treatment, (2) highlight preclinical studies of pharmacological agents commonly used in clinical practice which have HDT potential, and (3) outline developments in cellular therapy to promote clinically beneficial immunomodulation to improve treatment outcomes in patients with pulmonary MDR-TB. The use of HDTs as adjuncts to MDR-TB therapy requires urgent evaluation.
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Affiliation(s)
- Alimuddin Zumla
- Division of Infection and Immunity, University College London, and NIHR Biomedical Research Centre, UCL Hospitals NHS Foundation Trust, London, UK
| | - Martin Rao
- F79, Therapeutic Immunology (TIM) division, Department of Laboratory Medicine (LABMED), Karolinska University Hospital Huddinge, 14186, Stockholm, Sweden
| | - Ernest Dodoo
- F79, Therapeutic Immunology (TIM) division, Department of Laboratory Medicine (LABMED), Karolinska University Hospital Huddinge, 14186, Stockholm, Sweden
| | - Markus Maeurer
- F79, Therapeutic Immunology (TIM) division, Department of Laboratory Medicine (LABMED), Karolinska University Hospital Huddinge, 14186, Stockholm, Sweden. .,Centre for Allogeneic Stem Cell Transplantation (CAST), Karolinska University Hospital Huddinge, Stockholm, Sweden.
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Zumla A, Rao M, Parida SK, Keshavjee S, Cassell G, Wallis R, Axelsson-Robertsson R, Doherty M, Andersson J, Maeurer M. Inflammation and tuberculosis: host-directed therapies. J Intern Med 2015; 277:373-87. [PMID: 24717092 DOI: 10.1111/joim.12256] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Tuberculosis (TB) is an airborne infectious disease that kills almost two million individuals every year. Multidrug-resistant (MDR) TB is caused by strains of Mycobacterium tuberculosis (M. tb) resistant to isoniazid and rifampin, the backbone of first-line antitubercular treatment. MDR TB affects an estimated 500,000 new patients annually. Genetic analysis of drug-resistant MDR-TB showed that airborne transmission of undetected and untreated strains played a major role in disease outbreaks. The need for new TB vaccines and faster diagnostics, as well as the development of new drugs, has recently been highlighted. The major problem in terms of current TB research and clinical demands is the increasing number of cases of extensively drug-resistant and 'treatment-refractory' TB. An emerging scenario of adjunct host-directed therapies is intended to target pulmonary TB where inflammatory processes can be deleterious and lead to immune exhaustion. 'Target-organ-saving' strategies may be warranted to prevent damage to infected tissues and achieve focused, clinically relevant and long-lasting anti-M. tb cellular immune responses. Candidates for such interventions may be biological agents or already approved drugs that can be 're-purposed' to interfere with biologically relevant cellular checkpoints. Here, we review current concepts of inflammation in TB disease and discuss candidate pathways for host-directed therapies to achieve better clinical outcomes.
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Affiliation(s)
- A Zumla
- University College London, University College London Hospitals NHS Foundation Trust, London, UK
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9
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Immunoadjuvant Therapy and Noninvasive Ventilation for Acute Respiratory Failure in Lung Tuberculosis: A Case Study. Case Rep Pulmonol 2015; 2015:283867. [PMID: 26273486 PMCID: PMC4530232 DOI: 10.1155/2015/283867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 06/17/2015] [Accepted: 06/21/2015] [Indexed: 11/18/2022] Open
Abstract
Acute respiratory failure caused by pulmonary tuberculosis is a rare event but with a high mortality even while receiving mechanical ventilatory support. We report the case of a young man with severe pulmonary tuberculosis refractory to conventional therapy who successfully overcame the critical period of his condition using noninvasive ventilation and immunoadjuvant therapy that included three doses of etanercept 25 mg subcutaneously. We conclude that the use of etanercept along with antituberculosis treatment appears to be safe and effective in patients with pulmonary tuberculosis presenting with acute respiratory failure.
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10
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Skrahin A, Ahmed RK, Ferrara G, Rane L, Poiret T, Isaikina Y, Skrahina A, Zumla A, Maeurer MJ. Autologous mesenchymal stromal cell infusion as adjunct treatment in patients with multidrug and extensively drug-resistant tuberculosis: an open-label phase 1 safety trial. THE LANCET RESPIRATORY MEDICINE 2014; 2:108-22. [PMID: 24503266 DOI: 10.1016/s2213-2600(13)70234-0] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Novel treatment options are urgently needed for multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis, which are associated with immune dysfunction and poor treatment outcomes. Mesenchymal stromal cells (MSCs) are immunomodulatory and adjunct autologous treatment with bone marrow-derived MSCs might improve clinical outcome by transforming chronic inflammation into productive immune responses. Our aim was to assess the safety of infusion of autologous MSCs as an adjunct treatment in patients with tuberculosis. METHODS 30 patients with microbiologically confirmed MDR or XDR tuberculosis were treated with single-dose autologous bone marrow-derived MSCs (aimed for 1×10(6) cells per kg), within 4 weeks of the start of antituberculosis-drug treatment in a specialist centre in Minsk, Belarus. Inclusion patients were those with pulmonary tuberculosis confirmed by sputum smear microscopy, culture, or both; MDR or XDR tuberculosis confirmed by drug-susceptibility testing to first-line and second-line drugs; age older than 21 years to 65 years or younger; and absence of lesion compatible with a malignant process or ongoing tuberculosis in organs other than the lungs and pleura. In addition to the inclusion criteria, patients were excluded if they were pregnant, coinfected with HIV, or infected with hepatitis B, C, or both. The primary endpoint was safety measured by MSC-infusion related events; any tuberculosis-related event within the 6 month observation period that related to a worsening of the underlying infectious disease, measured by conversion of Mycobacterium tuberculosis culture or microscopic examination; or any adverse event defined clinically or by changes in blood haematology and biochemistry variables, measured monthly for 6 months after MSC infusion per protocol. This study is registered with the German Clinical Trials Registry, number DRKS00000763. FINDINGS The most common (grade 1 or 2) adverse events were high cholesterol levels (14 of 30 patients), nausea (11 of 30 patients), and lymphopenia or diarrhoea (ten of 30 patients). There were no serious adverse events reported. We recorded two grade 3 events that were transitory-ie, increased plasma potassium ion concentrations in one patient and a transitory grade 3 γ-glutamyltransferase elevation in another patient. INTERPRETATION MSCs as an adjunct therapy are safe and can now be explored further for the treatment of patients with MDR or XDR tuberculosis in combination with standard drug regimens. Adjunct treatment with MSCs needs to be evaluated in controlled phase 2 trials to assess effects on immune responses and clinical and microbiological outcomes.
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Affiliation(s)
- Aliaksandr Skrahin
- Republican Research and Practical Centre for Pulmonology and TB, Minsk, Belarus; Department of Intensive Care, Belarussian State Medical University, Minsk, Belarus
| | - Raija K Ahmed
- Swedish Institute for Infectious Disease Control (SMI), Solna, Sweden
| | - Giovanni Ferrara
- Section of Respiratory Diseases, Department of Internal Medicine, University of Perugia, Perugia, Italy
| | - Lalit Rane
- Department of Microbiology, Tumour and Cell Biology, MTC, Karolinska Institutet, Stockholm, Sweden
| | - Thomas Poiret
- Therapeutic Immunology (TIM), Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Yanina Isaikina
- Laboratory of Cellular Biotechnology and Cytotherapy, Belarussian Research Centre for Paediatric Oncology, Haematology and Immunology, Minsk, Belarus
| | - Alena Skrahina
- Republican Research and Practical Centre for Pulmonology and TB, Minsk, Belarus
| | - Alimuddin Zumla
- Division of Infection and Immunity, Centre for Clinical Microbiology, University College London, London, UK; National Institute of Health Research-Biomedical Research Centre, University College Hospitals NHS Foundation Trust, London, UK
| | - Markus J Maeurer
- Department of Microbiology, Tumour and Cell Biology, MTC, Karolinska Institutet, Stockholm, Sweden; Therapeutic Immunology (TIM), Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden; Centre for Allogeneic Stem Cell Transplantation, CAST, Karolinska University Hospital, Stockholm, Sweden.
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11
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Pulmonary tuberculosis presenting with acute respiratory distress syndrome (ARDS): A case report and review of literature. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2013. [DOI: 10.1016/j.ejcdt.2013.09.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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12
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Silva DR, Gazzana MB, Dalcin PDTR. Severe tuberculosis requiring ICU admission. J Bras Pneumol 2012; 38:386-94. [PMID: 22782610 DOI: 10.1590/s1806-37132012000300015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 05/04/2012] [Indexed: 01/09/2023] Open
Abstract
Tuberculosis is a curable disease that can evolve to severe forms, requiring the treatment of the patients in an ICU, especially if there is a delay in the diagnosis or if it affects elderly patients, those on dialysis, or those with HIV infection or other states of immunosuppression, as well as in cases of multidrug resistant disease. Knowledge of the radiological presentation of the cases can help diagnose these severe forms, as can the introduction of new tests, such as the early detection of the etiological agent by PCR and chest CT, which favors the early initiation of treatment. In addition, the use of regimens without isoniazid and rifampin, as well as uncertain enteral absorption and low serum concentrations of antituberculosis drugs, can reduce the efficacy of treatment. For such patients, the prognosis is generally poor and mortality rates are high.
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Tobin DM, Roca FJ, Oh SF, McFarland R, Vickery TW, Ray JP, Ko DC, Zou Y, Bang ND, Chau TTH, Vary JC, Hawn TR, Dunstan SJ, Farrar JJ, Thwaites GE, King MC, Serhan CN, Ramakrishnan L. Host genotype-specific therapies can optimize the inflammatory response to mycobacterial infections. Cell 2012; 148:434-46. [PMID: 22304914 PMCID: PMC3433720 DOI: 10.1016/j.cell.2011.12.023] [Citation(s) in RCA: 427] [Impact Index Per Article: 35.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Revised: 10/07/2011] [Accepted: 12/08/2011] [Indexed: 12/11/2022]
Abstract
Susceptibility to tuberculosis is historically ascribed to an inadequate immune response that fails to control infecting mycobacteria. In zebrafish, we find that susceptibility to Mycobacterium marinum can result from either inadequate or excessive acute inflammation. Modulation of the leukotriene A(4) hydrolase (LTA4H) locus, which controls the balance of pro- and anti-inflammatory eicosanoids, reveals two distinct molecular routes to mycobacterial susceptibility converging on dysregulated TNF levels: inadequate inflammation caused by excess lipoxins and hyperinflammation driven by excess leukotriene B(4). We identify therapies that specifically target each of these extremes. In humans, we identify a single nucleotide polymorphism in the LTA4H promoter that regulates its transcriptional activity. In tuberculous meningitis, the polymorphism is associated with inflammatory cell recruitment, patient survival and response to adjunctive anti-inflammatory therapy. Together, our findings suggest that host-directed therapies tailored to patient LTA4H genotypes may counter detrimental effects of either extreme of inflammation.
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Affiliation(s)
- David M. Tobin
- Department of Microbiology, University of Washington, Seattle, WA 98195
- Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC 27710
| | - Francisco J. Roca
- Department of Microbiology, University of Washington, Seattle, WA 98195
| | - Sungwhan F. Oh
- Center for Experimental Therapeutics and Reperfusion Injury, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02115
| | - Ross McFarland
- Department of Microbiology, University of Washington, Seattle, WA 98195
| | - Thad W. Vickery
- Center for Experimental Therapeutics and Reperfusion Injury, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02115
| | - John P. Ray
- Department of Microbiology, University of Washington, Seattle, WA 98195
| | - Dennis C. Ko
- Department of Microbiology, University of Washington, Seattle, WA 98195
| | - Yuxia Zou
- Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC 27710
| | - Nguyen D. Bang
- Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease, Ho Chi Minh City, Vietnam
| | - Tran T. H. Chau
- Hospital for Tropical Diseases, 190 Ben Ham Tu, Quan 5, Ho Chi Minh City, Vietnam
| | - Jay C. Vary
- Department of Medicine, University of Washington, Seattle, WA 98195
| | - Thomas R. Hawn
- Department of Medicine, University of Washington, Seattle, WA 98195
| | - Sarah J. Dunstan
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, 190 Ben Ham Tu, Quan 5, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford University, Oxford OX3 7LJ, UK
| | - Jeremy J. Farrar
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, 190 Ben Ham Tu, Quan 5, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford University, Oxford OX3 7LJ, UK
| | - Guy E. Thwaites
- Kings College London, Centre for Clinical Infection and Diagnostics Research, St. Thomas’ Hospital, London SE1 9RT, UK
| | - Mary-Claire King
- Department of Medicine, University of Washington, Seattle, WA 98195
- Department of Genome Sciences, University of Washington, Seattle, WA 98195
| | - Charles N. Serhan
- Center for Experimental Therapeutics and Reperfusion Injury, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02115
| | - Lalita Ramakrishnan
- Department of Microbiology, University of Washington, Seattle, WA 98195
- Department of Medicine, University of Washington, Seattle, WA 98195
- Department of Immunology, University of Washington, Seattle, WA 98195
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Koo MS, Manca C, Yang G, O'Brien P, Sung N, Tsenova L, Subbian S, Fallows D, Muller G, Ehrt S, Kaplan G. Phosphodiesterase 4 inhibition reduces innate immunity and improves isoniazid clearance of Mycobacterium tuberculosis in the lungs of infected mice. PLoS One 2011; 6:e17091. [PMID: 21364878 PMCID: PMC3045423 DOI: 10.1371/journal.pone.0017091] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2010] [Accepted: 01/18/2011] [Indexed: 11/18/2022] Open
Abstract
Tuberculosis (TB) caused by Mycobacterium tuberculosis (Mtb) is one of the leading infectious disease causes of morbidity and mortality worldwide. Though current antibiotic regimens can cure the disease, treatment requires at least six months of drug therapy. One reason for the long duration of therapy is that the currently available TB drugs were selected for their ability to kill replicating organisms and are less effective against subpopulations of non-replicating persistent bacilli. Evidence from in vitro models of Mtb growth and mouse infection studies suggests that host immunity may provide some of the environmental cues that drive Mtb towards non-replicating persistence. We hypothesized that selective modulation of the host immune response to modify the environmental pressure on the bacilli may result in better bacterial clearance during TB treatment. For this proof of principal study, we compared bacillary clearance from the lungs of Mtb-infected mice treated with the anti-TB drug isoniazid (INH) in the presence and absence of an immunomodulatory phosphodiesterase 4 inhibitor (PDE4i), CC-3052. The effects of CC-3052 on host global gene expression, induction of cytokines, and T cell activation in the lungs of infected mice were evaluated. We show that CC-3052 modulates the innate immune response without causing generalized immune suppression. Immune modulation combined with INH treatment improved bacillary clearance and resulted in smaller granulomas and less lung pathology, compared to treatment with INH alone. This novel strategy of combining anti-TB drugs with an immune modulating molecule, if applied appropriately to patients, may shorten the duration of TB treatment and improve clinical outcome.
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Affiliation(s)
- Mi-Sun Koo
- Laboratory of Mycobacterial Immunity and Pathogenesis, The Public Health Research Institute Center at the University of Medicine and Dentistry of New Jersey, Newark, New Jersey, United States of America
| | - Claudia Manca
- Laboratory of Mycobacterial Immunity and Pathogenesis, The Public Health Research Institute Center at the University of Medicine and Dentistry of New Jersey, Newark, New Jersey, United States of America
| | - Guibin Yang
- Laboratory of Mycobacterial Immunity and Pathogenesis, The Public Health Research Institute Center at the University of Medicine and Dentistry of New Jersey, Newark, New Jersey, United States of America
| | - Paul O'Brien
- Laboratory of Mycobacterial Immunity and Pathogenesis, The Public Health Research Institute Center at the University of Medicine and Dentistry of New Jersey, Newark, New Jersey, United States of America
| | - Nackmoon Sung
- Laboratory of Mycobacterial Immunity and Pathogenesis, The Public Health Research Institute Center at the University of Medicine and Dentistry of New Jersey, Newark, New Jersey, United States of America
- National Masan Hospital Clinical Research Center, Masan City Gyeongsangnam-do, South Korea
| | - Liana Tsenova
- Laboratory of Mycobacterial Immunity and Pathogenesis, The Public Health Research Institute Center at the University of Medicine and Dentistry of New Jersey, Newark, New Jersey, United States of America
| | - Selvakumar Subbian
- Laboratory of Mycobacterial Immunity and Pathogenesis, The Public Health Research Institute Center at the University of Medicine and Dentistry of New Jersey, Newark, New Jersey, United States of America
| | - Dorothy Fallows
- Laboratory of Mycobacterial Immunity and Pathogenesis, The Public Health Research Institute Center at the University of Medicine and Dentistry of New Jersey, Newark, New Jersey, United States of America
| | - George Muller
- Celgene Corporation, San Diego, California, United States of America
| | - Sabine Ehrt
- Department of Microbiology and Immunology, Weill Cornell Medical College, New York, New York, United States of America
| | - Gilla Kaplan
- Laboratory of Mycobacterial Immunity and Pathogenesis, The Public Health Research Institute Center at the University of Medicine and Dentistry of New Jersey, Newark, New Jersey, United States of America
- * E-mail:
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Misra A, Hickey AJ, Rossi C, Borchard G, Terada H, Makino K, Fourie PB, Colombo P. Inhaled drug therapy for treatment of tuberculosis. Tuberculosis (Edinb) 2011; 91:71-81. [DOI: 10.1016/j.tube.2010.08.009] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Revised: 08/12/2010] [Accepted: 08/29/2010] [Indexed: 11/16/2022]
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Ho JC, Ooi GC, Mok TY, Chan JW, Hung I, Lam B, Wong PC, Li PC, Ho PL, Lam WK, Ng CK, Ip MS, Lai KN, Chan-Yeung M, Tsang KW. High-dose pulse versus nonpulse corticosteroid regimens in severe acute respiratory syndrome. Am J Respir Crit Care Med 2003; 168:1449-56. [PMID: 12947028 DOI: 10.1164/rccm.200306-766oc] [Citation(s) in RCA: 149] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
The treatment of atypical pneumonia, subsequently termed severe acute respiratory syndrome (SARS), is controversial, and the efficacy of corticosteroid therapy is unknown. We have evaluated the clinical and radiographic outcomes of 72 patients with probable SARS (median age 37 years, 30 M), who received ribavirin and different steroid regimens in two regional hospitals. Chest radiographs were scored according to the percentage of lung field involved. Seventeen patients initially received pulse steroid (PS) (methylprednisolone > or =500 mg/day) and 55 patients initially received nonpulse steroid (NPS) (methylprednisolone <500 mg/day) therapy. The cumulative steroid dosage; intensive care unit admission, mechanical ventilation, and mortality rates; and hematologic and biochemical parameters were similar in both groups after 21 days. However, patients in the PS group had less oxygen requirement, better radiographic outcome, and less likelihood of requiring rescue PS therapy than their counterparts. There was no significant difference between the two groups in hemolytic anemia, severe secondary infections, or hematemesis, but patients in the PS group had less hyperglycaemia. Initial use of pulse methylprednisolone therapy appears to be a more efficacious and an equally safe steroid regimen when compared with regimens with lower dosage and should be considered as the preferred steroid regimen in the treatment of SARS, pending data from future randomized controlled trials.
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Affiliation(s)
- James C Ho
- University Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong SAR, People's Republic of China
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Abstract
Although deaths from tuberculosis (TB) are increasing, TB-related sudden death (TBRSD) is rarely reported in the literature. We present a case report of fatal pulmonary TB with extrapulmonary extension in a patient infected with the human immunodeficiency virus (HIV) and a review of published reports of TBRSD in MEDLINE (1966 to October 2000). Forty-six cases of TBRSD were reported. The most common cause of TBRSD was tuberculous bronchopneumonia in 30 (64%) patients, followed by hemoptysis in 14 (30%) patients. Tuberculous myocarditis and isolated TB of the adrenal glands are seldom causes of TBRSD. The early detection of TB, use of directly observed therapy, and individualization of treatment can be helpful in decreasing the incidence of TBRSD.
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Affiliation(s)
- S Alkhuja
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, St. Barnabas Hospital, Weill Medical College of Cornell University, Bronx, NY 10457-2594, USA
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Toossi Z. The Inflammatory Response in Mycobacterium Tuberculosis Infection. Inflammation 2001. [DOI: 10.1007/978-94-015-9702-9_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Mínguez C, Roca B, González-Miño C, Simón E. Superior vena cava syndrome during the treatment of pulmonary tuberculosis in an HIV-1 infected patient. J Infect 2000; 40:187-9. [PMID: 10841098 DOI: 10.1016/s0163-4453(00)80015-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Tuberculosis is nowadays an uncommon cause of superior vena cava syndrome (SVCS). We report the case of an HIV-infected patient who presented with respiratory symptoms accompanied by cervical and mediastinal lymphadenopathy. Sputum examination showed acid-fast bacilli, and treatment was instituted with isoniazid, rifampicin, pyrazinamide and ethambutol. A few days later SVCS developed, presumably as a consequence of inflammatory lymphadenitis. With corticosteroids, all symptoms disappeared. To our knowledge, no cases of SVCS provoked by this kind of paradoxical reaction have been described previously.
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Affiliation(s)
- C Mínguez
- Department of Medicine, Hospital General de Castellón, Spain
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Affiliation(s)
- R I Kopelman
- Department of Medicine, New England Medical Center, Tufts University School of Medicine, Boston, MA 02111, USA
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Affiliation(s)
- L Chan
- Division of Infectious Diseases, Children's Hospital Oakland, CA, USA
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Barakat MT, Scott J, Hughes JM, Walport M, Calam J, Friedland JS, Ind PW, McKenna C. Grand rounds--Hammersmith Hospital. Persistent fever in pulmonary tuberculosis. BMJ (CLINICAL RESEARCH ED.) 1996; 313:1543-5. [PMID: 8978236 PMCID: PMC2353037 DOI: 10.1136/bmj.313.7071.1543] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Wyser C, Walzl G, Smedema JP, Swart F, van Schalkwyk EM, van de Wal BW. Corticosteroids in the treatment of tuberculous pleurisy. A double-blind, placebo-controlled, randomized study. Chest 1996; 110:333-8. [PMID: 8697829 DOI: 10.1378/chest.110.2.333] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Although several studies on tuberculous (TB) pleurisy suggest that the addition of corticosteroids to anti-TB therapy may have beneficial effects, these agents are not used routinely. To assess the effects of short-term oral prednisone therapy in TB pleurisy, 74 patients were randomly assigned in a double-blind fashion to treatment with either placebo or prednisone at a dose of 0.75 mg/kg/d for up to 4 weeks with gradual reduction over an additional 2 weeks. All subjects received a standard 3-drug anti-TB chemotherapy regimen for 6 months. TB pleurisy was diagnosed by histologic study and/or culture of pleural biopsy specimens obtained at thoracoscopy. Complete drainage of the effusion was performed simultaneously. Outcome measures were assessed periodically for 24 weeks, including indexes of morbidity and pleural thickening. After randomization, four patients were excluded from the final analysis. Of the 70 patients analyzed, 34 received prednisone and 36 received placebo. Demographic and clinical characteristics of the treatment groups were comparable at the time of hospital admission. Although a statistically significant improvement in symptoms occurred earlier in the prednisone group (8 weeks) than in the placebo group (12 weeks), between-group comparison showed no significant differences at any of the follow-up evaluations. The proportion of subjects in the prednisone group (53.1%) with residual pleural thickening at 6 months did not differ significantly from that of the placebo group (60%). Pleural effusions did not recur in any of the patients. Initial complete drainage of the effusion was associated with greater symptomatic improvement than any subsequent therapy. We conclude that standard anti-TB therapy and early complete drainage is adequate for the treatment of TB pleurisy. The addition of short-term oral prednisone therapy neither results in clinically relevant earlier symptom relief nor confers a beneficial effect on residual pleural thickening.
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Affiliation(s)
- C Wyser
- Department of Internal Medicine, University of Stellenbosch, Cape Town, South Africa
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