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Kobayashi N, Tanaka K, Muraoka S, Somekawa K, Kaneko A, Kubo S, Matsumoto H, Fujii H, Watanabe K, Horita N, Hara Y, Kaneko T. Influence of age, IGRA results, and inflammatory markers on mortality in hospitalized tuberculosis patients. J Infect Chemother 2024; 30:48-52. [PMID: 37704163 DOI: 10.1016/j.jiac.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/05/2023] [Accepted: 09/10/2023] [Indexed: 09/15/2023]
Abstract
INTRODUCTION Tuberculosis (TB) remains a leading cause of death globally. Identifying the factors associated with mortality during hospitalization for TB is crucial for improving patient outcomes. This study aimed to investigate the potential risk factors, including T-SPOT.TB test results and routine laboratory markers of inflammation, associated with death during hospitalization due to TB. METHODS A retrospective analysis was conducted on 244 hospitalized TB patients. Demographic data, clinical characteristics, T-SPOT.TB results, and laboratory parameters were collected. Univariate and multivariate analyses were performed to identify independent risk factors for in-hospital mortality. RESULTS Among the patients, 206 survived and 38 died during hospitalization. Multivariate analysis revealed that age (HR: 1.08, 95% CI: 1.02-1.15, p = 0.001), a negative T-SPOT.TB test result (HR: 4.01, 95% CI: 1.78-9.01, p < 0.001), elevated C-reactive protein (CRP) levels (HR: 1.04, 95% CI: 1.01-1.08, p = 0.007), and increased neutrophil-to-lymphocyte ratio (NLR) (HR: 1.04, 95% CI: 1.00-1.07, p = 0.025) were independent risk factors for mortality. CONCLUSIONS This study identified age, a negative T-SPOT.TB result, elevated CRP levels, and a high NLR as significant independent risk factors for death in hospitalized TB patients. These findings underscore the importance of these parameters in the risk stratification and management of hospitalized TB patients. Further research is warranted to elucidate the mechanisms behind these associations and to validate these results in different populations.
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Affiliation(s)
- Nobuaki Kobayashi
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan.
| | - Katsushi Tanaka
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Suguru Muraoka
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Kohei Somekawa
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Ayami Kaneko
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Sousuke Kubo
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Hiromi Matsumoto
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Hiroaki Fujii
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Keisuke Watanabe
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Nobuyuki Horita
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Yu Hara
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Takeshi Kaneko
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
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Gebremicael G, Gebreegziabxier A, Kassa D. Low transcriptomic of PTPRCv1 and CD3E is an independent predictor of mortality in HIV and tuberculosis co-infected patient. Sci Rep 2022; 12:10133. [PMID: 35710869 PMCID: PMC9203579 DOI: 10.1038/s41598-022-14305-8] [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: 01/12/2022] [Accepted: 06/06/2022] [Indexed: 11/09/2022] Open
Abstract
A comprehensive assessment of immunological profiles during HIV-TB co-infection is essential to predict mortality, and facilitate the development of effective diagnostic assays, therapeutic agents, and vaccines. Expression levels of 105 immune-related genes were measured at enrolment and 6th month follow-up from 9 deceased HIV and TB coinfected patients who died between 3 and 7th months follow-up and at enrolment, 6th and 18th month from 18 survived matched controls groups for 2 years. Focused gene expression profiling was assessed from peripheral whole blood using a dual-color Reverse-Transcription Multiplex Ligation-dependent Probe Amplification assay. Eleven of the 105 selected genes were differentially expressed between deceased individuals and survivor-matched controls at baseline. At baseline, IL4δ2 was significantly more highly expressed in the deceased group than survivor matched controls, whereas CD3E, IL7R, PTPRCv1, CCL4, GNLY, BCL2, CCL5, NOD1, TLR3, and NLRP13 had significantly lower expression levels in the deceased group compared to survivor matched controls. At baseline, a non-parametric receiver operator characteristic curve was conducted to determine the prediction of mortality of single genes identified CCL5, PTPRCv1, CD3E, and IL7R with Area under the Curve of 0.86, 0.86, 0.86, and 0.85 respectively. The expression of these genes in the survived control was increased at the end of TB treatment from that at baseline, while decreased in the deceased group. The expression of PTPRCv1, CD3E, CCL5, and IL7R host genes in peripheral blood of patients with TB-HIV coinfected can potentially be used as a predictor of mortality in the Ethiopian setting. Anti-TB treatment might be less likely to restore gene expression in the level expression of the deceased group. Therefore, other new therapeutics that can restore these genes (PTPRCv1, CD3E, IL7R, and CCL5) in the deceased groups at baseline might be needed to save lives.
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Affiliation(s)
| | | | - Desta Kassa
- Ethiopian Public Health Institute (EPHI), P.O.Box: 1242, Addis Ababa, Ethiopia
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Ojo T, Ruan C, Hameed T, Malburg C, Thunga S, Smith J, Vieira D, Snyder A, Tampubolon SJ, Gyamfi J, Ryan N, Lim S, Santacatterina M, Peprah E. HIV, Tuberculosis, and Food Insecurity in Africa—A Syndemics-Based Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19031101. [PMID: 35162131 PMCID: PMC8834641 DOI: 10.3390/ijerph19031101] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/16/2022] [Accepted: 01/16/2022] [Indexed: 12/13/2022]
Abstract
The double burden of HIV/AIDS and tuberculosis (TB), coupled with endemic and problematic food insecurity in Africa, can interact to negatively impact health outcomes, creating a syndemic. For people living with HIV/AIDS (PWH), food insecurity is a significant risk factor for acquiring TB due to the strong nutritional influences and co-occurring contextual barriers. We aim to synthesize evidence on the syndemic relationship between HIV/AIDS and TB co-infection and food insecurity in Africa. We conducted a scoping review of studies in Africa that included co-infected adults and children, with evidence of food insecurity, characterized by insufficient to lack of access to macronutrients. We sourced information from major public health databases. Qualitative, narrative analysis was used to synthesize the data. Of 1072 articles screened, 18 articles discussed the syndemic effect of HIV/AIDS and TB co-infection and food insecurity. Reporting of food insecurity was inconsistent, however, five studies estimated it using a validated scale. Food insecure co-infected adults had an average BMI of 16.5–18.5 kg/m2. Negative outcomes include death (n = 6 studies), depression (n = 1 study), treatment non-adherence, weight loss, wasting, opportunistic infections, TB-related lung diseases, lethargy. Food insecurity was a precursor to co-infection, especially with the onset/increased incidence of TB in PWH. Economic, social, and facility-level factors influenced the negative impact of food insecurity on the health of co-infected individuals. Nutritional support, economic relief, and psychosocial support minimized the harmful effects of food insecurity in HIV–TB populations. Interventions that tackle one or more components of a syndemic interaction can have beneficial effects on health outcomes and experiences of PWH with TB in Africa.
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Affiliation(s)
- Temitope Ojo
- Implementing Sustainable Evidence-Based Interventions through Engagement (ISEE) Lab, Global Health Program, Department of Social and Behavioral Sciences, School of Global Public Health, New York University (NYU), 708 Broadway, 4th Floor, New York, NY 10003, USA; (C.R.); (T.H.); (C.M.); (S.T.); (J.S.); (D.V.); (A.S.); (S.J.T.); (J.G.); (N.R.); (E.P.)
- Correspondence: ; Tel.: +1-203-690-9449
| | - Christina Ruan
- Implementing Sustainable Evidence-Based Interventions through Engagement (ISEE) Lab, Global Health Program, Department of Social and Behavioral Sciences, School of Global Public Health, New York University (NYU), 708 Broadway, 4th Floor, New York, NY 10003, USA; (C.R.); (T.H.); (C.M.); (S.T.); (J.S.); (D.V.); (A.S.); (S.J.T.); (J.G.); (N.R.); (E.P.)
| | - Tania Hameed
- Implementing Sustainable Evidence-Based Interventions through Engagement (ISEE) Lab, Global Health Program, Department of Social and Behavioral Sciences, School of Global Public Health, New York University (NYU), 708 Broadway, 4th Floor, New York, NY 10003, USA; (C.R.); (T.H.); (C.M.); (S.T.); (J.S.); (D.V.); (A.S.); (S.J.T.); (J.G.); (N.R.); (E.P.)
| | - Carly Malburg
- Implementing Sustainable Evidence-Based Interventions through Engagement (ISEE) Lab, Global Health Program, Department of Social and Behavioral Sciences, School of Global Public Health, New York University (NYU), 708 Broadway, 4th Floor, New York, NY 10003, USA; (C.R.); (T.H.); (C.M.); (S.T.); (J.S.); (D.V.); (A.S.); (S.J.T.); (J.G.); (N.R.); (E.P.)
| | - Sukruthi Thunga
- Implementing Sustainable Evidence-Based Interventions through Engagement (ISEE) Lab, Global Health Program, Department of Social and Behavioral Sciences, School of Global Public Health, New York University (NYU), 708 Broadway, 4th Floor, New York, NY 10003, USA; (C.R.); (T.H.); (C.M.); (S.T.); (J.S.); (D.V.); (A.S.); (S.J.T.); (J.G.); (N.R.); (E.P.)
| | - Jaimie Smith
- Implementing Sustainable Evidence-Based Interventions through Engagement (ISEE) Lab, Global Health Program, Department of Social and Behavioral Sciences, School of Global Public Health, New York University (NYU), 708 Broadway, 4th Floor, New York, NY 10003, USA; (C.R.); (T.H.); (C.M.); (S.T.); (J.S.); (D.V.); (A.S.); (S.J.T.); (J.G.); (N.R.); (E.P.)
| | - Dorice Vieira
- Implementing Sustainable Evidence-Based Interventions through Engagement (ISEE) Lab, Global Health Program, Department of Social and Behavioral Sciences, School of Global Public Health, New York University (NYU), 708 Broadway, 4th Floor, New York, NY 10003, USA; (C.R.); (T.H.); (C.M.); (S.T.); (J.S.); (D.V.); (A.S.); (S.J.T.); (J.G.); (N.R.); (E.P.)
- NYU Health Sciences Library, 550 First Avenue, New York, NY 10016, USA
| | - Anya Snyder
- Implementing Sustainable Evidence-Based Interventions through Engagement (ISEE) Lab, Global Health Program, Department of Social and Behavioral Sciences, School of Global Public Health, New York University (NYU), 708 Broadway, 4th Floor, New York, NY 10003, USA; (C.R.); (T.H.); (C.M.); (S.T.); (J.S.); (D.V.); (A.S.); (S.J.T.); (J.G.); (N.R.); (E.P.)
| | - Siphra Jane Tampubolon
- Implementing Sustainable Evidence-Based Interventions through Engagement (ISEE) Lab, Global Health Program, Department of Social and Behavioral Sciences, School of Global Public Health, New York University (NYU), 708 Broadway, 4th Floor, New York, NY 10003, USA; (C.R.); (T.H.); (C.M.); (S.T.); (J.S.); (D.V.); (A.S.); (S.J.T.); (J.G.); (N.R.); (E.P.)
| | - Joyce Gyamfi
- Implementing Sustainable Evidence-Based Interventions through Engagement (ISEE) Lab, Global Health Program, Department of Social and Behavioral Sciences, School of Global Public Health, New York University (NYU), 708 Broadway, 4th Floor, New York, NY 10003, USA; (C.R.); (T.H.); (C.M.); (S.T.); (J.S.); (D.V.); (A.S.); (S.J.T.); (J.G.); (N.R.); (E.P.)
| | - Nessa Ryan
- Implementing Sustainable Evidence-Based Interventions through Engagement (ISEE) Lab, Global Health Program, Department of Social and Behavioral Sciences, School of Global Public Health, New York University (NYU), 708 Broadway, 4th Floor, New York, NY 10003, USA; (C.R.); (T.H.); (C.M.); (S.T.); (J.S.); (D.V.); (A.S.); (S.J.T.); (J.G.); (N.R.); (E.P.)
| | - Sahnah Lim
- Section for Health Equity, Department of Population Health, NYU Langone Health, 180 Madison Avenue, New York, NY 10016, USA;
| | - Michele Santacatterina
- Division of Biostatistics, Department of Population Health, NYU Langone Health, 180 Madison Avenue, New York, NY 10016, USA;
| | - Emmanuel Peprah
- Implementing Sustainable Evidence-Based Interventions through Engagement (ISEE) Lab, Global Health Program, Department of Social and Behavioral Sciences, School of Global Public Health, New York University (NYU), 708 Broadway, 4th Floor, New York, NY 10003, USA; (C.R.); (T.H.); (C.M.); (S.T.); (J.S.); (D.V.); (A.S.); (S.J.T.); (J.G.); (N.R.); (E.P.)
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Ter Beek L, Bolhuis MS, Jager-Wittenaar H, Brijan RXD, Sturkenboom MGG, Kerstjens HAM, de Lange WCM, Tiberi S, van der Werf TS, Alffenaar JWC, Akkerman OW. Malnutrition assessment methods in adult patients with tuberculosis: a systematic review. BMJ Open 2021; 11:e049777. [PMID: 35344503 PMCID: PMC8719177 DOI: 10.1136/bmjopen-2021-049777] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 11/19/2021] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Malnutrition is associated with a twofold higher risk of dying in patients with tuberculosis (TB) and considered an important potentially reversible risk factor for failure of TB treatment. The construct of malnutrition has three domains: intake or uptake of nutrition; body composition and physical and cognitive function. The objectives of this systematic review are to identify malnutrition assessment methods, and to quantify how malnutrition assessment methods capture the international consensus definition for malnutrition, in patients with TB. DESIGN Different assessment methods were identified. We determined the extent of capturing of the three domains of malnutrition, that is, intake or uptake of nutrition, body composition and physical and cognitive function. RESULTS Seventeen malnutrition assessment methods were identified in 69 included studies. In 53/69 (77%) of studies, body mass index was used as the only malnutrition assessment method. Three out of 69 studies (4%) used a method that captured all three domains of malnutrition. CONCLUSIONS Our study focused on published articles. Implementation of new criteria takes time, which may take longer than the period covered by this review. Most patients with TB are assessed for only one aspect of the conceptual definition of malnutrition. The use of international consensus criteria is recommended to establish uniform diagnostics and treatment of malnutrition. PROSPERO REGISTRATION NUMBER CRD42019122832.
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Affiliation(s)
- Lies Ter Beek
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Tuberculosis Center Beatrixoord, University of Groningen, University Medical Center Groningen, Haren, The Netherlands
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, and Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Mathieu S Bolhuis
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Harriët Jager-Wittenaar
- Research Group Healthy Ageing, Allied Health Care and Nursing, Hanze University of Applied Sciences, Groningen, The Netherlands
- Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - René X D Brijan
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, and Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Marieke G G Sturkenboom
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Huib A M Kerstjens
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Wiel C M de Lange
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Tuberculosis Center Beatrixoord, University of Groningen, University Medical Center Groningen, Haren, The Netherlands
| | - Simon Tiberi
- Department of Infection, Barts Health NHS Trust, London, UK
- Blizard Institute, Queen Mary University of London, London, UK
| | - Tjip S van der Werf
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan-Willem C Alffenaar
- Faculty of Medicine and Health, University of Sydney, School of Pharmacy, Sydney, New South Wales, Australia
- Westmead Hospital, Sydney, New South Wales, Australia
- Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia
| | - Onno W Akkerman
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Tuberculosis Center Beatrixoord, University of Groningen, University Medical Center Groningen, Haren, The Netherlands
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Gama WM, Frank CHM, Almeida TVR, Dos Santos DS, Chaves YO, da Silva DF, Orlandi PP, Pereira FR, Magalhães GF, Baptista BJ, de Oliveira Silva VL, da Silva Balieiro AA, Santana MF, Gonçalves RL, da Costa AG, Dos Santos MC, de Lima Ferreira LC, Lacerda MVG, Nogueira PA. Immunologic biomarkers, morbidity and mortality among HIV patients hospitalised in a Tertiary Care Hospital in the Brazilian Amazon. BMC Infect Dis 2021; 21:876. [PMID: 34445956 PMCID: PMC8394190 DOI: 10.1186/s12879-021-06566-x] [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] [Received: 08/23/2020] [Accepted: 08/12/2021] [Indexed: 11/23/2022] Open
Abstract
Background The irregular use of antiretroviral therapy (ART) and late diagnosis still account for a large part of HIV-associated mortality in people living with HIV (PLHIV). Herein, we describe HIV-associated morbidity among hospitalised HIV/AIDS patients with advanced immunosuppression and assess the comorbidities, laboratory parameters, and immunological markers associated with mortality. Methods The cross-sectional study was conducted at the Fundação de Medicina Tropical Doutor Heitor Vieira Dourado (FMT-HVD) in Manaus, Brazil. In all, 83 participants aged between 12 and 70 years were enrolled by convenience within 72 h of their hospitalisation. Clinical and laboratory data were obtained from electronic medical records. We prospectively measured the cytokines Th1/Th2/Th17 and inflammatory cytokines IL-8, IL-1β, and IL-12 using cytometric bead array, and the soluble CD14 using in-house enzyme-linked immunosorbent assay. Results The HIV/AIDS inpatients presented a scenario of respiratory syndromes as the most prevalent comorbidity. Almost all patients had CD4 T counts below 350 cells/mL and the mortality rate was 20.5%. Pulmonary tuberculosis, neurotoxoplasmosis and oropharyngeal–esophageal candidiasis were the most prevalent opportunistic infections. TB and weight loss were more prevalent in HIV/AIDS inpatients who died. The Mann Whitney analysis showed that those who died had higher platelet distribution width (PDW) on admission, which is suggestive for platelet activation. The Poisson multivariate analysis showed the prevalence of TB, digestive syndrome and increases in IL-8 and lactate dehydrogenase (LDH) associated to death. Conclusions The advanced immunosuppression characterized by the opportunistic infections presented in these HIV/AIDS inpatients was the major factor of mortality. The role of platelet activation in worse outcomes of hospitalisation and the IL-8 associated with the context of advanced immunosuppression may be promising markers in the prediction of mortality in HIV/AIDS patients.
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Affiliation(s)
- Wellington Mota Gama
- Programa de Pós-Graduação em Imunologia Básica e Aplicada, Universidade Federal do Amazonas, Manaus, Brazil
| | | | | | - Daniel Silva Dos Santos
- Programa de Pós-Graduação em Biologia da Relação Patógeno Hospedeiro, Instituto Leônidas e Maria Deane, Manaus, Brazil
| | - Yury Oliveira Chaves
- Programa de Pós-Graduação em Biologia da Relação Patógeno Hospedeiro, Instituto Leônidas e Maria Deane, Manaus, Brazil.,Programa de Pós-Graduação em Biologia Parasitária, Instituto Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Danielle Furtado da Silva
- Programa de Pós-Graduação em Imunologia Básica e Aplicada, Universidade Federal do Amazonas, Manaus, Brazil
| | - Patrícia Puccinelli Orlandi
- Programa de Pós-Graduação em Biologia da Relação Patógeno Hospedeiro, Instituto Leônidas e Maria Deane, Manaus, Brazil.,Instituto Aggeu Magalhaes, Fundação Oswaldo Cruz-Fiocruz, Recife, Brazil
| | | | - Gleicienne Feliz Magalhães
- Programa de Pós-Graduação em Imunologia Básica e Aplicada, Universidade Federal do Amazonas, Manaus, Brazil
| | | | | | - Antônio Alcirley da Silva Balieiro
- Programa de Pós-Graduação em Biologia da Relação Patógeno Hospedeiro, Instituto Leônidas e Maria Deane, Manaus, Brazil.,Programa de Pós-Graduação em Biologia Parasitária, Instituto Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Monique Freire Santana
- Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Roberta Lins Gonçalves
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal do Amazonas, Manaus, Brazil
| | - Allyson Guimarães da Costa
- Programa de Pós-Graduação em Imunologia Básica e Aplicada, Universidade Federal do Amazonas, Manaus, Brazil.,Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil.,Diretoria de Ensino e Pesquisa, Fundação Hospitalar de Hematologia e Hemoterapia do Amazonas, Manaus, Brazil.,Programa de Pós-Graduação em Ciências Aplicadas à Hematologia, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Marcelo Cordeiro Dos Santos
- Instituto Aggeu Magalhaes, Fundação Oswaldo Cruz-Fiocruz, Recife, Brazil.,Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Luís Carlos de Lima Ferreira
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil.,Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal do Amazonas, Manaus, Brazil.,Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Marcus Vinicius Guimaraes Lacerda
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil.,Programa de Pós-Graduação em Biologia da Relação Patógeno Hospedeiro, Instituto Leônidas e Maria Deane, Manaus, Brazil.,Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Paulo Afonso Nogueira
- Programa de Pós-Graduação em Imunologia Básica e Aplicada, Universidade Federal do Amazonas, Manaus, Brazil. .,Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil. .,Programa de Pós-Graduação em Biologia da Relação Patógeno Hospedeiro, Instituto Leônidas e Maria Deane, Manaus, Brazil.
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Schutz C, Barr D, Andrade BB, Shey M, Ward A, Janssen S, Burton R, Wilkinson KA, Sossen B, Fukutani KF, Nicol M, Maartens G, Wilkinson RJ, Meintjes G. Clinical, microbiologic, and immunologic determinants of mortality in hospitalized patients with HIV-associated tuberculosis: A prospective cohort study. PLoS Med 2019; 16:e1002840. [PMID: 31276515 PMCID: PMC6611568 DOI: 10.1371/journal.pmed.1002840] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 05/24/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND In high-burden settings, case fatality rates are reported to be between 11% and 32% in hospitalized patients with HIV-associated tuberculosis, yet the underlying causes of mortality remain poorly characterized. Understanding causes of mortality could inform the development of novel management strategies to improve survival. We aimed to assess clinical and microbiologic determinants of mortality and to characterize the pathophysiological processes underlying death by evaluating host soluble inflammatory mediators and determined the relationship between these mediators and death as well as biomarkers of disseminated tuberculosis. METHODS AND FINDINGS Adult patients with HIV hospitalized with a new diagnosis of HIV-associated tuberculosis were enrolled in Cape Town between 2014 and 2016. Detailed tuberculosis diagnostic testing was performed. Biomarkers of tuberculosis dissemination and host soluble inflammatory mediators at baseline were assessed. Of 682 enrolled participants, 576 with tuberculosis (487/576, 84.5% microbiologically confirmed) were included in analyses. The median age was 37 years (IQR = 31-43), 51.2% were female, and the patients had advanced HIV with a median cluster of differentiation 4 (CD4) count of 58 cells/L (IQR = 21-120) and a median HIV viral load of 5.1 log10 copies/mL (IQR = 3.3-5.7). Antituberculosis therapy was initiated in 566/576 (98.3%) and 487/576 (84.5%) started therapy within 48 hours of enrolment. Twelve-week mortality was 124/576 (21.5%), with 46/124 (37.1%) deaths occurring within 7 days of enrolment. Clinical and microbiologic determinants of mortality included disseminated tuberculosis (positive urine lipoarabinomannan [LAM], urine Xpert MTB/RIF, or tuberculosis blood culture in 79.6% of deaths versus 60.7% of survivors, p = 0.001), sepsis syndrome (high lactate in 50.8% of deaths versus 28.9% of survivors, p < 0.001), and rifampicin-resistant tuberculosis (16.9% of deaths versus 7.2% of survivors, p = 0.002). Using non-supervised two-way hierarchical cluster and principal components analyses, we describe an immune profile dominated by mediators of the innate immune system and chemotactic signaling (interleukin-1 receptor antagonist [IL-1Ra], IL-6, IL-8, macrophage inflammatory protein-1 beta [MIP-1β]/C-C motif chemokine ligand 4 [CCL4], interferon gamma-induced protein-10 [IP-10]/C-X-C motif chemokine ligand 10 [CXCL10], MIP-1 alpha [MIP-1α]/CCL3), which segregated participants who died from those who survived. This immune profile was associated with mortality in a Cox proportional hazards model (adjusted hazard ratio [aHR] = 2.2, 95%CI = 1.9-2.7, p < 0.001) and with detection of biomarkers of disseminated tuberculosis. Clinicians attributing causes of death identified tuberculosis as a cause or one of the major causes of death in 89.5% of cases. We did not perform longitudinal sampling and did not have autopsy-confirmed causes of death. CONCLUSIONS In this study, we did not identify a major contribution from coinfections to these deaths. Disseminated tuberculosis, sepsis syndrome, and rifampicin resistance were associated with mortality. An immune profile dominated by mediators of the innate immune system and chemotactic signaling was associated with both tuberculosis dissemination and mortality. These findings provide pathophysiologic insights into underlying causes of mortality and could be used to inform the development of novel treatment strategies and to develop methods to risk stratify patients to appropriately target novel interventions. Causal relationships cannot be established from this study.
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Affiliation(s)
- Charlotte Schutz
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - David Barr
- Wellcome Trust Liverpool Glasgow Centre for Global Health Research, University of Liverpool, Liverpool, United Kingdom
| | - Bruno B. Andrade
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Universidade Salvador (UNIFACS), Laureate Universities, Salvador, Brazil
| | - Muki Shey
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Amy Ward
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Saskia Janssen
- Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Rosie Burton
- Khayelitsha Hospital, Department of Medicine, Cape Town, South Africa
| | - Katalin A. Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- The Francis Crick Institute, London, United Kingdom
| | - Bianca Sossen
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kiyoshi F. Fukutani
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
- Faculdade de Tecnologia e Ciências (FTC), Salvador, Brazil
| | - Mark Nicol
- Division of Medical Microbiology, University of Cape Town and National Health Laboratory Services, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Robert J. Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- The Francis Crick Institute, London, United Kingdom
- Department of Medicine, Imperial College, London, United Kingdom
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
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