1
|
Hermans SM, Akkerman OW, Meintjes G, Grobusch MP. Post-tuberculosis treatment paradoxical reactions. Infection 2024:10.1007/s15010-024-02310-0. [PMID: 38955990 DOI: 10.1007/s15010-024-02310-0] [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: 04/11/2024] [Accepted: 05/28/2024] [Indexed: 07/04/2024]
Abstract
Paradoxical reactions (PR) to tuberculosis (TB) treatment are common during treatment, but have also been described after treatment. A presentation with recurrent signs or symptoms of TB after cure or completion of prior treatment needs to be differentiated between microbiological relapse and a paradoxical reaction. We searched all published literature on post-treatment PR, and present a synthesis of 30 studies, focusing on the epidemiology, diagnosis and management of this phenomenon. We report an additional case vignette. The majority of studies were of lymph node TB (LN-TB), followed by central nervous system TB (CNS-TB). A total of 112 confirmed and 42 possible post-treatment PR cases were reported. The incidence ranged between 3 and 14% in LN-TB and was more frequent than relapses, and between 0 and 2% in all TB. We found four reports of pulmonary or pleural TB post-treatment PR cases. The incidence did not differ by length of treatment, but was associated with younger age at initial diagnosis, and having had a PR (later) during treatment. Post-treatment PR developed mainly within the first 6 months after the end of TB treatment but has been reported many years later (longest report 10 years). The mainstays of diagnosis and management are negative mycobacterial cultures and anti-inflammatory treatment, respectively. Due to the favourable prognosis in LN-TB recurrent symptoms, a short period of observation is warranted to assess for spontaneous regression. In CNS-TB with recurrent symptoms, immediate investigation and anti-inflammatory treatment with the possibility of TB retreatment should be undertaken.
Collapse
Affiliation(s)
- Sabine M Hermans
- Centre for Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam Public Health-Global Health, Amsterdam Infection and Immunity, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands.
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands.
| | - Onno W Akkerman
- Department of Pulmonary Diseases and Tuberculosis, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
- University Medical Centre Groningen, TB Centre Beatrixoord, University of Groningen, Groningen, The Netherlands
| | - Graeme Meintjes
- 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
- Blizard Institute, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Martin P Grobusch
- Centre for Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam Public Health-Global Health, Amsterdam Infection and Immunity, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Institute of Tropical Medicine, University of Tuebingen, Tübingen, Germany
- Centre de Recherches Médicales en Lambaréné (CERMEL), Lambaréné, Gabon
- Masanga Medical Research Unit (MMRU), Masanga, Sierra Leone
| |
Collapse
|
2
|
Tan DTM, See KC. Diagnosis and management of severe pulmonary and extrapulmonary tuberculosis in critically ill patients: A mini review for clinicians. World J Crit Care Med 2024; 13:91435. [PMID: 38855275 PMCID: PMC11155508 DOI: 10.5492/wjccm.v13.i2.91435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 02/04/2024] [Accepted: 03/25/2024] [Indexed: 06/03/2024] Open
Abstract
Among critically ill patients, severe pulmonary and extrapulmonary tuberculosis has high morbidity and mortality. Yet, it is a diagnostic challenge given its nonspecific clinical symptoms and signs in early stages of the disease. In addition, management of severe pulmonary and extrapulmonary tuberculosis is complicated given the high risk of drug-drug interactions, drug-disease interactions, and adverse drug reactions. To help clinicians acquire an up-to-date approach to severe tuberculosis, this paper will provide a narrative review of contemporary diagnosis and management of severe pulmonary and extrapulmonary tuberculosis in critically ill patients.
Collapse
Affiliation(s)
- Dominic Ti Ming Tan
- Department of Medicine, National University Hospital, Singapore 119228, Singapore
| | - Kay Choong See
- Department of Medicine, National University Hospital, Singapore 119228, Singapore
| |
Collapse
|
3
|
Clement OO, Cooper BL. Man with chest pain, fever, and surprising finding on bedside ultrasound. J Am Coll Emerg Physicians Open 2024; 5:e13209. [PMID: 38813138 PMCID: PMC11134222 DOI: 10.1002/emp2.13209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 05/06/2024] [Accepted: 05/16/2024] [Indexed: 05/31/2024] Open
Affiliation(s)
- Omoyeni O. Clement
- Department of Emergency MedicineMcGovern Medical School at UTHealth HoustonHoustonTexasUSA
| | - Benjamin L. Cooper
- Department of Emergency MedicineMcGovern Medical School at UTHealth HoustonHoustonTexasUSA
| |
Collapse
|
4
|
Le X, Shen Y. Advances in Antiretroviral Therapy for Patients with Human Immunodeficiency Virus-Associated Tuberculosis. Viruses 2024; 16:494. [PMID: 38675837 PMCID: PMC11054420 DOI: 10.3390/v16040494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/09/2024] [Accepted: 03/22/2024] [Indexed: 04/28/2024] Open
Abstract
Tuberculosis is one of the most common opportunistic infections and a prominent cause of death in patients with human immunodeficiency virus (HIV) infection, in spite of near-universal access to antiretroviral therapy (ART) and tuberculosis preventive therapy. For patients with active tuberculosis but not yet receiving ART, starting ART after anti-tuberculosis treatment can complicate clinical management due to drug toxicities, drug-drug interactions and immune reconstitution inflammatory syndrome (IRIS) events. The timing of ART initiation has a crucial impact on treatment outcomes, especially for patients with tuberculous meningitis. The principles of ART in patients with HIV-associated tuberculosis are specific and relatively complex in comparison to patients with other opportunistic infections or cancers. In this review, we summarize the current progress in the timing of ART initiation, ART regimens, drug-drug interactions between anti-tuberculosis and antiretroviral agents, and IRIS.
Collapse
Affiliation(s)
| | - Yinzhong Shen
- Department of Infection and Immunity, Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China;
| |
Collapse
|
5
|
Coelho LE, Chazallon C, Laureillard D, Escada R, N’takpe JB, Timana I, Messou E, Eholie S, Khosa C, Chau GD, Cardoso SW, Veloso VG, Delaugerre C, Molina JM, Grinsztejn B, Marcy O, De Castro N. Incidence and Predictors of Tuberculosis-associated IRIS in People With HIV Treated for Tuberculosis: Findings From Reflate TB2 Randomized Trial. Open Forum Infect Dis 2024; 11:ofae035. [PMID: 38486816 PMCID: PMC10939434 DOI: 10.1093/ofid/ofae035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 01/18/2024] [Indexed: 03/17/2024] Open
Abstract
Background After antiretroviral therapy (ART) initiation, people with HIV (PWH) treated for tuberculosis (TB) may develop TB-associated immune reconstitution inflammatory syndrome (TB-IRIS). Integrase inhibitors, by providing a faster HIV-RNA decline than efavirenz, might increase the risk for this complication. We sought to assess incidence and determinants of TB-IRIS in PWH with TB on raltegravir- or efavirenz-based ART. Methods We conducted a secondary analysis of the Reflate TB 2 trial, which randomized ART-naive PWH on standard TB treatment, to receive raltegravir- or efavirenz-based ART. The primary objective was to evaluate the incidence of TB-IRIS. Incidence rate ratio comparing TB-IRIS incidence in each arm was calculated. Kaplan-Meier curves were used to compare TB-IRIS-free survival probabilities by ART arm. Cox regression models were fitted to analyze baseline characteristics associated with TB-IRIS. Results Of 460 trial participants, 453 from Brazil, Côte d'Ivoire, Mozambique, and Vietnam were included in this analysis. Baseline characteristics were median age 35 years (interquartile range [IQR], 29-43), 40% female, 69% pulmonary TB only, median CD4, 102 (IQR, 38-239) cells/mm³, and median HIV RNA, 5.5 (IQR, 5.0-5.8) log copies/mL. Forty-eight participants developed TB-IRIS (incidence rate, 24.7/100 PY), 19 cases in the raltegravir arm and 29 in the efavirenz arm (incidence rate ratio 0.62, 95% confidence interval .35-1.10). Factors associated with TB-IRIS were: CD4 ≤ 100 cells/μL, HIV RNA ≥500 000 copies/mL, and extrapulmonary/disseminated TB. Conclusions We did not demonstrate that raltegravir-based ART increased the incidence of TB-IRIS compared with efavirenz-based ART. Low CD4 counts, high HIV RNA, and extrapulmonary/disseminated TB at ART initiation were associated with TB-IRIS.
Collapse
Affiliation(s)
- Lara E Coelho
- National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Corine Chazallon
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Centre, University of Bordeaux, Bordeaux, France
| | - Didier Laureillard
- Department of Infectious and Tropical Diseases, Nimes University Hospital, Nimes, France
- Research Unit 1058, Pathogenesis and Control Chronical Infections, INSERM, French Blood Center, University of Montpellier, Montpellier, France
| | - Rodrigo Escada
- National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Jean-Baptiste N’takpe
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Centre, University of Bordeaux, Bordeaux, France
- Programme PACCI/ANRS Research Center, Abidjan, Côte-d'Ivoire
| | | | - Eugène Messou
- Programme PACCI/ANRS Research Center, Abidjan, Côte-d'Ivoire
- Centre de Prise en Charge de Recherche et de Formation, CePReF-Aconda-VS, Abidjan, Cote D'Ivoire
- Département de Dermatologie et d'Infectiologie, UFR des Sciences Médicales, Université Félix Houphouët Boigny, Abidjan, Cote d'Ivoire
| | - Serge Eholie
- Programme PACCI/ANRS Research Center, Abidjan, Côte-d'Ivoire
- Département de Dermatologie et d'Infectiologie, UFR des Sciences Médicales, Université Félix Houphouët Boigny, Abidjan, Cote d'Ivoire
| | - Celso Khosa
- Instituto Nacional de Saúde, Marracuene, Mozambique
| | - Giang D Chau
- Pham Ngoc Thach Hospital, Ho Chi Minh City, Vietnam
| | - Sandra Wagner Cardoso
- National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Valdiléa G Veloso
- National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Constance Delaugerre
- Virology department, APHP-Hôpital Saint-Louis, Paris, France
- INSERM U944, Paris, France
- Université Paris Cité, Paris, France
| | - Jean-Michel Molina
- INSERM U944, Paris, France
- Université Paris Cité, Paris, France
- Infectious Diseases Department, AP-HP-Hôpital Saint-Louis Lariboisière, Paris, France
| | - Beatriz Grinsztejn
- National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Olivier Marcy
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Centre, University of Bordeaux, Bordeaux, France
| | - Nathalie De Castro
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Centre, University of Bordeaux, Bordeaux, France
- Infectious Diseases Department, AP-HP-Hôpital Saint-Louis Lariboisière, Paris, France
| |
Collapse
|
6
|
Gerber F, Semphere R, Lukau B, Mahlatsi P, Mtenga T, Lee T, Kohler M, Glass TR, Amstutz A, Molatelle M, MacPherson P, Marake NB, Nliwasa M, Ayakaka I, Burke R, Labhardt N. Same-day versus rapid ART initiation in HIV-positive individuals presenting with symptoms of tuberculosis: Protocol for an open-label randomized non-inferiority trial in Lesotho and Malawi. PLoS One 2024; 19:e0288944. [PMID: 38330045 PMCID: PMC10852279 DOI: 10.1371/journal.pone.0288944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 12/21/2023] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND In absence of contraindications, same-day initiation (SDI) of antiretroviral therapy (ART) is recommended for people testing HIV-positive who are ready to start treatment. Until 2021, World Health Organization (WHO) guidelines considered the presence of TB symptoms (presumptive TB) a contraindication to SDI due to the risk of TB-immune reconstitution inflammatory syndrome (TB-IRIS). To reduce TB-IRIS risk, ART initiation was recommended to be postponed until results of TB investigations were available, and TB treatment initiated if active TB was confirmed. In 2021, the WHO guidelines changed to recommending SDI even in the presence of TB symptoms without awaiting results of TB investigations based on the assumption that TB investigations often unnecessarily delay ART initiation, increasing the risk for pre-ART attrition from care, and noting that the clinical relevance of TB-IRIS outside the central nervous system remains unclear. However, this guideline change was not based on conclusive evidence, and it remains unclear whether SDI of ART or TB test results should be prioritized in people with HIV (PWH) and presumptive TB. DESIGN AND METHODS SaDAPT is an open-label, pragmatic, parallel, 1:1 individually randomized, non-inferiority trial comparing two strategies for the timing of ART initiation in PWH with presumptive TB ("ART first" versus "TB results first"). PWH in Lesotho and Malawi, aged 12 years and older (re)initiating ART who have at least one TB symptom (cough, fever, night sweats or weight loss) and no signs of intracranial infection are eligible. After a baseline assessment, participants in the "ART first" arm will be offered SDI of ART, while those in the "TB results first" arm will be offered ART only after active TB has been confirmed or refuted. We hypothesize that the "ART first" approach is safe and non-inferior to the "TB results first" approach with regard to HIV viral suppression (<400 copies/ml) six months after enrolment. Secondary outcomes include retention in care and adverse events consistent with TB-IRIS. EXPECTED OUTCOMES SaDAPT will provide evidence on the safety and effects of SDI of ART in PWH with presumptive TB in a pragmatic clinical trial setting. TRIAL REGISTRATION The trial has been registered on clinicaltrials.gov (NCT05452616; July 11 2022).
Collapse
Affiliation(s)
- Felix Gerber
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Robina Semphere
- Helse Nord Tuberculosis Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | | | - Timeo Mtenga
- Helse Nord Tuberculosis Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Tristan Lee
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Maurus Kohler
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Tracy Renée Glass
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Alain Amstutz
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Oslo Center for Biostatistics and Epidemiology, Oslo University Hospital, University of Oslo, Oslo, Norway
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | | | - Peter MacPherson
- School of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | | | - Marriot Nliwasa
- Helse Nord Tuberculosis Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Rachael Burke
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Niklaus Labhardt
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| |
Collapse
|
7
|
Yang H, Liu Q, Wu Y, He K, Zeng Q, Liu M. Paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome in initiating ART among HIV-Infected patients in China-risk factors and management. BMC Infect Dis 2024; 24:5. [PMID: 38166781 PMCID: PMC10759358 DOI: 10.1186/s12879-023-08897-3] [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: 10/18/2023] [Accepted: 12/12/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND China is a country burdened with a high incidence of both tuberculosis (TB) and HIV, Paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is an important early complication in TB and HIV co-infected patients, but data from China are limited. Additionally, as an integrase strand transfer inhibitor (INSTI)-based antiretroviral therapy (ART) regimen becomes the first-line treatment, concerns have arisen regarding the potential increase in the incidence of paradoxical TB-IRIS. Nevertheless, the existing data are inconclusive and contradictory. METHODS We conducted a retrospective study at Chongqing Public Health Clinical Center from January 2018 to December 2021. We collected demographic and clinical data of HIV/TB co-infected patients who initiated ART. We described the patient characteristics, identified predictors for TB-IRIS, and determined clinical outcomes. The Statistical Package for Social Science (SPSS 25) was used to analyse the data. Continuous variables were compared using Student's t-test or rank sum test. Counting data were compared using the chi-square test or Fisher's exact test. The variables with statistical significance in the univariate analysis were added to the binary logistic regression. A p-value less than 0.05 was considered statistically significant. RESULTS A total of 384 patients co-infected with naive HIV and pulmonary TB (PTB) who were given ATT and ART combination were included. 72 patients (18.8%) developed paradoxical TB-IRIS with a median of 15 (12, 21) days after initiating ART. Baseline age ≤ 40years, CD4 + T-cell counts ≤ 50cells/µL, HIV viral load ≥ 500,000 copies/mL were found to be significantly associated with development of paradoxical TB-IRIS. Mortality rates were similar in the TB-IRIS (n = 5, 6.9%) group and non-TB-IRIS (n = 13, 4.2%) group. Interestingly, CD4+ T-cell counts recovery post-ART was significant higher in the TB-IRIS group when compared to the non-TB-IRIS group at the end of 24 weeks (P = 0.004), as well as at 48 weeks (P = 0.015). In addition, we consider that INSTI- based ART regimen do not increased the risk of Paradoxical TB-IRIS. CONCLUSION Paradoxical TB-IRIS, while often leading to clinical deterioration and hospitalization, is generally manageable. It appears to have a positive impact on the recovery of CD4 + T-cell counts over time. Importantly, our data suggest that INSTI-based ART regimens do not elevate the risk of TB-IRIS. Thus, paradoxical TB-IRIS should not be considered an impediment to initiating ART in adults with advanced immunodeficiency, except in the case of tuberculous meningitis (TBM).
Collapse
Affiliation(s)
- Honghong Yang
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China
| | - Qian Liu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China
| | - Yushan Wu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China
| | - Kun He
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China
| | - Qin Zeng
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China
| | - Min Liu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China.
| |
Collapse
|
8
|
Kouamou V, Gundidza P, Ndhlovu CE, Makadzange AT. Factors associated with CD4 + cell count recovery among males and females with advanced HIV disease. AIDS 2023; 37:2311-2318. [PMID: 37598355 DOI: 10.1097/qad.0000000000003695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
OBJECTIVE HIV/AIDS mortality remains significantly high in sub-Saharan Africa, mostly driven by opportunistic infections and advanced HIV disease (AHD). This study aimed to assess CD4 + cell count recovery following ART initiation and factors associated with immune reconstitution. METHODS We conducted a prospective cohort study between 2015 and 2016. HIV-infected adults (≥18 years) with AHD (CD4 + cell count ≤100 cells/μl) receiving care at 20 outpatient HIV treatment facilities in Harare, Zimbabwe were enrolled. CD4 + cell count recovery (CD4 + cell count >200 cells/μl) was assessed following 12-month ART initiation and factors associated with immune reconstitution were investigated using logistic regression analysis. All statistical analyses were performed on Statistical Package for the Social Sciences (SPSS) version 23. RESULTS 1320 participants were enrolled and 56.4% were males. The median (interquartile range, IQR) age was 37 (32-43) years. Tuberculosis was seen in 16.0%. Of the 739 participants that had CD4 + cell count at 12 months, CD4 + cell count recovery above 200 cells/μl was observed in 163 (22.1%) participants. Median (IQR) CD4 + cell count at 12-months increased to 127 (75-190) cells/μl from 31 (14-55) at baseline. Factors associated with CD4 + cell count recovery were younger age at baseline [odds ratio (OR) ≥40/<40 = 0.58, 95% confidence interval (CI): 0.40-0.85, P = 0.005), sex (OR female/male = 2.07, 95% CI: 1.44-2.99, P < 0.0001) and baseline CD4 + cell count (OR ≥50/<50 = 1.60, 95% CI: 1.10-2.33, P = 0.013). CONCLUSION A significant proportion (77.9%) of patients seeking care with AHD in a resource limited setting failed to recover a CD4 + cell count >200 cells/μl. Male sex, older age and low CD4 + cell count at ART initiation were factors associated with poor immune reconstitution. Better differentiated care deliveries targeting this vulnerable population are critical for improving clinical outcomes and quality of life of the patients.
Collapse
Affiliation(s)
- Vinie Kouamou
- Charles River Medical Group
- Unit of Internal Medicine, Department of Primary Healthcare Sciences, University of Zimbabwe, Harare, Zimbabwe
| | | | - Chiratidzo Ellen Ndhlovu
- Charles River Medical Group
- Unit of Internal Medicine, Department of Primary Healthcare Sciences, University of Zimbabwe, Harare, Zimbabwe
| | | |
Collapse
|
9
|
Pean P, Madec Y, Nerrienet E, Borand L, Laureillard D, Fernandez M, Marcy O, Scott-Algara D. Natural Killer Repertoire Restoration in TB/HIV Co-Infected Individuals Experienced an Immune Reconstitution Syndrome (CAMELIA Trial, ANRS 12153). Pathogens 2023; 12:1241. [PMID: 37887757 PMCID: PMC10610037 DOI: 10.3390/pathogens12101241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/06/2023] [Accepted: 10/07/2023] [Indexed: 10/28/2023] Open
Abstract
IRIS is a common complication in HIV-infected patients treated for tuberculosis (TB) and cART. Our aim was to evaluate NK cell reconstitution in HIV-infected patients with TB-IRIS compared to those without IRIS. 147 HIV-infected patients with TB from the CAMELIA trial were enrolled. HIV+TB+ patients were followed for 32 weeks. The NK cell repertoire was assessed in whole blood at different time points. As CAMELIA has two arms (early and late cART initiation), we analysed them separately. At enrolment, individuals had low CD4 cell counts (27 cells/mm3) and high plasma viral loads (5.76 and 5.50 log/mL for IRIS and non-IRIS individuals, respectively). Thirty-seven people developed IRIS (in the early and late arms). In the early and late arms, we observed similar proportions of total NK and NK cell subsets in TB-IRIS and non-IRIS individuals during follow-up, except for the CD56dimCD16pos (both arms) and CD56dimCD16neg (late arm only) subsets, which were higher in TB-IRIS and non-IRIS individuals, respectively, after cART. Regarding the repertoire and markers of NK cells, significant differences (lower expression of NKp30, NKG2A (CD159a), NKG2D (CD314) were observed in TB-IRIS compared to non-IRIS individuals after the start of cART. In the late arm, some changes (increased expression of CD69, NKG2C, CD158i) were observed in TB-IRIS compared to non-IRIS individuals, but only before cART initiation (during TB treatment). KIR expression by NK cells (CD158a and CD158i) was similar in both groups. CD69 expression by NK cells decreased in all groups. Expression of the NCR repertoire (NKp30, NKp44, NKp46) has similar kinetics in TB-IRIS subjects compared to non-IRIS subjects regardless of the arm analysed. NK cell reconstitution appeared to be better in TB-IRIS subjects. Although NK cell reconstitution is impaired in HIV infection after cART, as previously reported, it does not appear to be affected by the development of IRIS in HIV and TB-infected individuals.
Collapse
Affiliation(s)
- Polidy Pean
- Immunology Unit, Institute Pasteur du Cambodge, Phnom Pen 12000, Cambodia
| | - Yoann Madec
- Epidemiology of Emerging Diseases, Institut Pasteur, Université de Paris, 75000 Paris, France;
| | | | - Laurence Borand
- Clinical Research Team, Epidemiology and Public Health Unit, Institut Pasteur du Cambodge, Phom Penh 12000, Cambodia;
- Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD 20600, USA
| | - Didier Laureillard
- Infectious and Tropical Diseases Department, University Hospital, 30900 Nimes, France;
| | | | - Olivier Marcy
- Research Institute for Sustainable Development (IRD) EMR 271, National Institute for Health and Medical Research (INSERM) UMR 1219, University of Bordeaux, 33000 Bordeaux, France;
| | - Daniel Scott-Algara
- Unité de Biologie Cellulaire et Lymphocytes, Institut Pasteur, 75000 Paris, France;
| |
Collapse
|
10
|
Hashiba T, Sugahara M, Ota Y, Kaseda K, Kashiwagi Y, Nakamura M, Shinohara T, Ikeda M, Okugawa S, Sugimoto K, Sasaki K, Hamasaki Y, Yamada D, Kume H, Moriya K, Nangaku M. Paralytic Ileus during Treatment of Pulmonary and Renal Tuberculosis in a Non-Human Immunodeficiency Virus Patient: An Unusual Presentation of Tuberculosis-immune Reconstitution Inflammatory Syndrome. Intern Med 2023; 62:2559-2564. [PMID: 36642517 PMCID: PMC10518560 DOI: 10.2169/internalmedicine.0898-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 11/29/2022] [Indexed: 01/15/2023] Open
Abstract
Paralytic ileus as tuberculosis-immune reconstitution inflammatory syndrome (TB-IRIS) is extremely rare. We herein report a 44-year-old man with pulmonary and renal tuberculosis who developed paralytic ileus 14 days after starting antituberculosis therapy (ATT) despite an initial favorable response to ATT. Paralytic ileus was successfully managed with conservative care. He initially required hemodialysis because of obstructive uropathy due to renal tuberculosis, but he was able to withdraw from dialysis after placement of ureteral stents. TB-IRIS can affect organs other than the original sites of tuberculosis, and the combined use of steroids may be effective for its prevention and treatment.
Collapse
Affiliation(s)
- Toyohiro Hashiba
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital, Japan
| | - Mai Sugahara
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital, Japan
| | - Yui Ota
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital, Japan
| | - Ken Kaseda
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital, Japan
| | - Yusuke Kashiwagi
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital, Japan
| | - Motonobu Nakamura
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital, Japan
| | - Takayuki Shinohara
- Department of Infectious Diseases, the University of Tokyo Hospital, Japan
| | - Mahoko Ikeda
- Department of Infectious Diseases, the University of Tokyo Hospital, Japan
| | - Shu Okugawa
- Department of Infectious Diseases, the University of Tokyo Hospital, Japan
| | - Kazuma Sugimoto
- Department of Urology, the University of Tokyo Hospital, Japan
| | - Kenichi Sasaki
- Department of Urology, the University of Tokyo Hospital, Japan
| | - Yoshifumi Hamasaki
- Department of Hemodialysis & Apheresis, the University of Tokyo Hospital, Japan
| | - Daisuke Yamada
- Department of Urology, the University of Tokyo Hospital, Japan
- Department of Hemodialysis & Apheresis, the University of Tokyo Hospital, Japan
| | - Haruki Kume
- Department of Urology, the University of Tokyo Hospital, Japan
| | - Kyoji Moriya
- Department of Infectious Diseases, the University of Tokyo Hospital, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital, Japan
- Department of Hemodialysis & Apheresis, the University of Tokyo Hospital, Japan
| |
Collapse
|
11
|
Stek C, Shey M, Mnika K, Schutz C, Thienemann F, Wilkinson RJ, Lynen L, Meintjes G. Relationship Between LTA4H Promotor Polymorphism and Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome and Its Prevention With Prednisone. Open Forum Infect Dis 2023; 10:ofad379. [PMID: 37520416 PMCID: PMC10375423 DOI: 10.1093/ofid/ofad379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/14/2023] [Indexed: 08/01/2023] Open
Abstract
The development of paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) and its prevention using prednisone may potentially be mediated by the LTA4H genotype. We assessed this hypothesis in a clinical trial evaluating prednisone to prevent TB-IRIS. We did not find an association between LTA4H genotype and TB-IRIS incidence or prednisone efficacy.
Collapse
Affiliation(s)
- Cari Stek
- Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Muki Shey
- Wellcome Center for Infectious Diseases Research in 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
| | - Khuthala Mnika
- Division of Human Genetics, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Charlotte Schutz
- Wellcome Center for Infectious Diseases Research in 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
| | - Friedrich Thienemann
- Wellcome Center for Infectious Diseases Research in 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
| | - Robert J Wilkinson
- Wellcome Center for Infectious Diseases Research in 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
- Francis Crick Institute, London, United Kingdom
- Department of Infectious Diseases, Imperial College London, London, United Kingdom
| | - Lutgarde Lynen
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Graeme Meintjes
- Wellcome Center for Infectious Diseases Research in 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
| |
Collapse
|
12
|
Wen L, Shi L, Wan SS, Xu T, Zhang L, Zhou ZG. Changes in the balance of Th17/Treg cells and oxidative stress markers in patients with HIV‑associated pulmonary tuberculosis who develop IRIS. Exp Ther Med 2023; 25:271. [PMID: 37206552 PMCID: PMC10189753 DOI: 10.3892/etm.2023.11970] [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: 07/01/2022] [Accepted: 02/23/2023] [Indexed: 05/21/2023] Open
Abstract
Tuberculosis (TB) is the most common opportunistic infection in patients with acquired immunodeficiency syndrome (AIDS) caused by human immunodeficiency virus (HIV) infection and is one of the primary causes of death from AIDS. The increased accessibility to highly active antiretroviral therapy (HAART) has significantly improved the clinical outcome of patients with HIV infection. However, following ART, rapid restoration of the immune system leads to immune reconstitution inflammatory syndrome (IRIS). Oxidative stress and innate immunity play a role in TB-associated IRIS (TB-IRIS). The present study investigated the changes that occur in oxidative stress markers and T helper (Th)17/regulatory T (Treg) cell balance and their significance in IRIS patients with HIV-associated pulmonary TB. A total of 316 patients with HIV-associated pulmonary TB were treated with HAART and followed up regularly for 12 weeks. Those who developed IRIS were included in the IRIS group (n=60), while the remaining patients were included in the non-IRIS group (n=256). The changes in plasma oxidative stress markers superoxide dismutase (SOD) and malondialdehyde (MDA) were detected with the ELISA, and the ratio of Th17 to Treg cells in whole blood were analyzed before and after treatment through the flow cytometric assay. Following treatment, MDA and Th17 cells levels were significantly increased while SOD and Treg cells levels were decreased in the IRIS group (P<0.05) compared with before treatment. In the non-IRIS group, a non-significant decrease was observed in SOD levels (P>0.05), while the MDA levels significantly decreased compared with before treatment (P<0.05) and the Th17 and Treg cells levels were both significantly increased (P<0.05). After treatment, compared with the non-IRIS group, the IRIS group showed a significant increase in MDA and Th17 cells and decrease in SOD and Treg cells levels (P<0.05). In addition, Th17 cells levels were positively correlated with MDA but negatively correlated with SOD levels. Treg levels were negatively correlated with MDA and positively correlated with SOD levels (P<0.05). The area under the curve values of serum MDA and SOD, Th17 and Treg levels predicting the occurrence of IRIS were 0.738, 0.883, 0.722 and 0.719, respectively (P<0.05). These results indicated that the above parameters have certain diagnostic value for the occurrence of IRIS. The occurrence of IRIS in patients with HIV-associated pulmonary TB may be associated with oxidative stress and Th17/Treg cell imbalance.
Collapse
Affiliation(s)
- Long Wen
- Department of Respiratory and Critical Care Medicine, The Affiliated Changsha Hospital of Xiangya School of Medicine, Central South University, The First Hospital of Changsha, Changsha, Hunan 410000, P.R. China
| | - Lei Shi
- Department of Nursing, The Fourth Hospital of Changsha, Changsha, Hunan 410000, P.R. China
| | - Shan-Shan Wan
- Department of Respiratory and Critical Care Medicine, The Affiliated Changsha Hospital of Xiangya School of Medicine, Central South University, The First Hospital of Changsha, Changsha, Hunan 410000, P.R. China
| | - Tao Xu
- Department of Respiratory and Critical Care Medicine, The Affiliated Changsha Hospital of Xiangya School of Medicine, Central South University, The First Hospital of Changsha, Changsha, Hunan 410000, P.R. China
| | - Lei Zhang
- Department of Respiratory Medicine, Yicheng People's Hospital of Shandong, Zaozhuang, Shandong 277300, P.R. China
- Correspondence to: Dr Zhi-Guo Zhou, Department of Respiratory and Critical Care Medicine, The Affiliated Changsha Hospital of Xiangya School of Medicine, Central South University, The First Hospital of Changsha, 311 Yingpan Road, Kaifu, Changsha, Hunan 410000, P.R. China
| | - Zhi-Guo Zhou
- Department of Respiratory and Critical Care Medicine, The Affiliated Changsha Hospital of Xiangya School of Medicine, Central South University, The First Hospital of Changsha, Changsha, Hunan 410000, P.R. China
- Correspondence to: Dr Zhi-Guo Zhou, Department of Respiratory and Critical Care Medicine, The Affiliated Changsha Hospital of Xiangya School of Medicine, Central South University, The First Hospital of Changsha, 311 Yingpan Road, Kaifu, Changsha, Hunan 410000, P.R. China
| |
Collapse
|
13
|
Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome-An Extempore Game of Misfiring with Defense Arsenals. Pathogens 2023; 12:pathogens12020210. [PMID: 36839482 PMCID: PMC9964757 DOI: 10.3390/pathogens12020210] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 01/21/2023] [Accepted: 01/28/2023] [Indexed: 01/31/2023] Open
Abstract
The lethal combination involving TB and HIV, known as "syndemic" diseases, synergistically act upon one another to magnify the disease burden. Individuals on anti-retroviral therapy (ART) are at risk of developing TB-associated immune reconstitution inflammatory syndrome (TB-IRIS). The underlying inflammatory complication includes the rapid restoration of immune responses following ART, eventually leading to exaggerated inflammatory responses to MTB antigens. TB-IRIS continues to be a cause of morbidity and mortality among HIV/TB coinfected patients initiating ART, and although a significant quantum of knowledge has been acquired on the pathogenesis of IRIS, the underlying pathomechanisms and identification of a sensitive and specific diagnostic marker still remain a grey area of investigation. Here, we reviewed the latest research developments into IRIS immunopathogenesis, and outlined the modalities to prevent and manage strategies for better clinical and diagnostic outcomes for IRIS.
Collapse
|
14
|
Moseki RM, Barber DL, Du Bruyn E, Shey M, Van der Plas H, Wilkinson RJ, Meintjes G, Riou C. Phenotypic Profile of Mycobacterium tuberculosis-Specific CD4 T-Cell Responses in People With Advanced Human Immunodeficiency Virus Who Develop Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome. Open Forum Infect Dis 2023; 10:ofac546. [PMID: 36726536 PMCID: PMC9879713 DOI: 10.1093/ofid/ofac546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 10/17/2022] [Indexed: 01/28/2023] Open
Abstract
Background Tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is a frequent complication of cotreatment for TB and human immunodeficiency virus (HIV)-1. We characterized Mycobacterium tuberculosis (Mtb)-specific CD4 T-cell phenotype and transcription factor profile associated with the development of TB-IRIS. Methods We examined the role of CD4 T-cell transcription factors in a murine model of mycobacterial IRIS. In humans, we used a longitudinal study design to compare the magnitude of antiretroviral therapy, activation, transcription factor profile, and cytotoxic potential of Mtb-specific CD4 T cells between TB-IRIS (n = 25) and appropriate non-IRIS control patients (n = 18) using flow cytometry. Results In the murine model, CD4 T-cell expression of Eomesodermin (Eomes), but not Tbet, was associated with experimentally induced IRIS. In patients, TB-IRIS onset was associated with the expansion of Mtb-specific IFNγ+CD4 T cells (P = .039). Patients with TB-IRIS had higher HLA-DR expression (P = .016), but no differences in the expression of T-bet or Eomes were observed. At TB-IRIS onset, Eomes+Tbet+Mtb-specific IFNγ+CD4+ T cells showed higher expression of granzyme B in patients with TB-IRIS (P = .026). Conclusions Although the murine model of Mycobacterium avium complex-IRIS suggests that Eomes+CD4 T cells underly IRIS, TB-IRIS was not associated with Eomes expression in patients. Mycobacterium tuberculosis-specific IFNγ+CD4 T-cell responses in TB-IRIS patients are differentiated, highly activated, and potentially cytotoxic.
Collapse
Affiliation(s)
- Raymond M Moseki
- Wellcome Center for Infectious Diseases Research in Africa (CIDRI-Africa), University of Cape Town, Cape Town, South Africa.,Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
| | - Daniel L Barber
- T Lymphocyte Biology Section, Laboratory of Parasitic Diseases, National Institute of Health, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Elsa Du Bruyn
- Wellcome Center for Infectious Diseases Research in Africa (CIDRI-Africa), University of Cape Town, Cape Town, South Africa.,Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
| | - Muki Shey
- Wellcome Center for Infectious Diseases Research in Africa (CIDRI-Africa), University of Cape Town, Cape Town, South Africa.,Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Helen Van der Plas
- Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa.,Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Robert J Wilkinson
- Wellcome Center for Infectious Diseases Research in Africa (CIDRI-Africa), University of Cape Town, Cape Town, South Africa.,Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa.,Department of Medicine, University of Cape Town, Cape Town, South Africa.,Department of Infectious Diseases, Imperial College London, London, United Kingdom.,The Francis Crick Institute, London, United Kingdom
| | - Graeme Meintjes
- Wellcome Center for Infectious Diseases Research in Africa (CIDRI-Africa), University of Cape Town, Cape Town, South Africa.,Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa.,Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Catherine Riou
- Wellcome Center for Infectious Diseases Research in Africa (CIDRI-Africa), University of Cape Town, Cape Town, South Africa.,Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa.,Department of Pathology, Division of Medical Virology, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
15
|
Schaberg T, Brinkmann F, Feiterna-Sperling C, Geerdes-Fenge H, Hartmann P, Häcker B, Hauer B, Haas W, Heyckendorf J, Lange C, Maurer FP, Nienhaus A, Otto-Knapp R, Priwitzer M, Richter E, Salzer HJ, Schoch O, Schönfeld N, Stahlmann R, Bauer T. Tuberkulose im Erwachsenenalter. Pneumologie 2022; 76:727-819. [DOI: 10.1055/a-1934-8303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
ZusammenfassungDie Tuberkulose ist in Deutschland eine seltene, überwiegend gut behandelbare Erkrankung. Weltweit ist sie eine der häufigsten Infektionserkrankungen mit ca. 10 Millionen Neuerkrankungen/Jahr. Auch bei einer niedrigen Inzidenz in Deutschland bleibt Tuberkulose insbesondere aufgrund der internationalen Entwicklungen und Migrationsbewegungen eine wichtige Differenzialdiagnose. In Deutschland besteht, aufgrund der niedrigen Prävalenz der Erkrankung und der damit verbundenen abnehmenden klinischen Erfahrung, ein Informationsbedarf zu allen Aspekten der Tuberkulose und ihrer Kontrolle. Diese Leitlinie umfasst die mikrobiologische Diagnostik, die Grundprinzipien der Standardtherapie, die Behandlung verschiedener Organmanifestationen, den Umgang mit typischen unerwünschten Arzneimittelwirkungen, die Besonderheiten in der Diagnostik und Therapie resistenter Tuberkulose sowie die Behandlung bei TB-HIV-Koinfektion. Sie geht darüber hinaus auf Versorgungsaspekte und gesetzliche Regelungen wie auch auf die Diagnosestellung und präventive Therapie einer latenten tuberkulösen Infektion ein. Es wird ausgeführt, wann es der Behandlung durch spezialisierte Zentren bedarf.Die Aktualisierung der S2k-Leitlinie „Tuberkulose im Erwachsenenalter“ soll allen in der Tuberkuloseversorgung Tätigen als Richtschnur für die Prävention, die Diagnose und die Therapie der Tuberkulose dienen und helfen, den heutigen Herausforderungen im Umgang mit Tuberkulose in Deutschland gewachsen zu sein.
Collapse
Affiliation(s)
- Tom Schaberg
- Deutsches Zentralkomitee zur Bekämpfung der Tuberkulose e. V. (DZK), Berlin
| | - Folke Brinkmann
- Abteilung für pädiatrische Pneumologie/CF-Zentrum, Universitätskinderklinik der Ruhr-Universität Bochum, Bochum
| | - Cornelia Feiterna-Sperling
- Klinik für Pädiatrie mit Schwerpunkt Pneumologie, Immunologie und Intensivmedizin, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt-Universität zu Berlin, Berlin
| | | | - Pia Hartmann
- Labor Dr. Wisplinghoff Köln, Klinische Infektiologie, Köln
- Department für Klinische Infektiologie, St. Vinzenz-Hospital, Köln
| | - Brit Häcker
- Deutsches Zentralkomitee zur Bekämpfung der Tuberkulose e. V. (DZK), Berlin
| | | | | | - Jan Heyckendorf
- Klinik für Innere Medizin I, Universitätsklinikum Schleswig-Holstein, Campus Kiel
| | - Christoph Lange
- Klinische Infektiologie, Forschungszentrum Borstel
- Deutsches Zentrum für Infektionsforschung (DZIF), Standort Hamburg-Lübeck-Borstel-Riems
- Respiratory Medicine and International Health, Universität zu Lübeck, Lübeck
- Baylor College of Medicine and Texas Childrenʼs Hospital, Global TB Program, Houston, TX, USA
| | - Florian P. Maurer
- Nationales Referenzzentrum für Mykobakterien, Forschungszentrum Borstel, Borstel
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Albert Nienhaus
- Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP), Universitätsklinikum Hamburg Eppendorf (UKE), Hamburg
| | - Ralf Otto-Knapp
- Deutsches Zentralkomitee zur Bekämpfung der Tuberkulose e. V. (DZK), Berlin
| | | | | | | | | | | | - Ralf Stahlmann
- Institut für klinische Pharmakologie und Toxikologie, Charité Universitätsmedizin, Berlin
| | - Torsten Bauer
- Deutsches Zentralkomitee zur Bekämpfung der Tuberkulose e. V. (DZK), Berlin
- Lungenklinik Heckeshorn, Helios Klinikum Emil von Behring, Berlin
| |
Collapse
|
16
|
Wouters E, Stek C, Swartz A, Buyze J, Schutz C, Thienemann F, Wilkinson RJ, Meintjes G, Lynen L, Nöstlinger C. Prednisone for the prevention of tuberculosis-associated IRIS (randomized controlled trial): Impact on the health-related quality of life. Front Psychol 2022; 13:983028. [PMID: 36275235 PMCID: PMC9581134 DOI: 10.3389/fpsyg.2022.983028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/18/2022] [Indexed: 11/18/2022] Open
Abstract
Background Tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is an important complication in patients with HIV-associated tuberculosis (TB) starting antiretroviral treatment (ART) in sub-Saharan Africa. The PredART-trial recently showed that prophylactic prednisone reduces the incidence of paradoxical TB-IRIS by 30% in a population at high risk. This paper reports the impact of the intervention on health-related quality of life (HRQoL), a secondary endpoint of the trial, measured by an amended version of the PROQOL-HIV instrument—the instrument’s validity and reliability is also assessed. Methods A total of 240 adult participants (antiretroviral treatment (ART)-naïve, TB-HIV co-infected with CD4 count ≤100 cells/μL) were recruited and randomized (1:1) to (1) a prednisone arm or (2) a placebo arm. In this sub-study of the PredART-trial we evaluated (1) the performance of an HIV-specific HR-QoL instrument amended for TB-IRIS, i.e., the PROQOL-HIV/TB in patients with HIV-associated TB starting ART (reliability, internal and external construct validity and invariance across time) and (2) the impact of prednisone on self-reported HR-QoL in this population through mixed models. Results The PROQOL-HIV/TB scale displayed acceptable internal reliability and good internal and external validity. This instrument, including the factor structure with the eight sub-dimensions, can thus be applied for measuring HR-QoL among HIV-TB patients at high risk for TB-IRIS. Prophylactic prednisone was statistically significantly associated only with the ‘Physical Health and Symptoms’-subscale: a four-week course of prednisone resulted in an earlier improvement in the physical dimension of HR-QoL compared to placebo. Conclusion We demonstrated that the PROQOL-HIV/TB scale adequately measures different aspects of self-reported HR-QoL in HIV-TB patients. Although more research is needed to understand how other domains related to HR-QoL can be improved, targeting patients at high risk for developing TB-IRIS with a four-week course of prednisone has a beneficial effect on the physical aspects of patient-reported quality of life.
Collapse
Affiliation(s)
- Edwin Wouters
- Centre for Population, Family & Health, University of Antwerp, Antwerp, Belgium
- Centre for Health Systems Research & Development, University of the Free State, Bloemfontein, South Africa
- *Correspondence: Edwin Wouters,
| | - Cari Stek
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Alison Swartz
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Jozefien Buyze
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Charlotte Schutz
- Wellcome Centre for Infectious Diseases Research in 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
| | - Friedrich Thienemann
- Wellcome Centre for Infectious Diseases Research in 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
| | - Robert J. Wilkinson
- Department of Medicine, Imperial College London, London, United Kingdom
- The Francis Crick Institute, London, United Kingdom
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in 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
| | - Lutgarde Lynen
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | | |
Collapse
|
17
|
Mbandi SK, Painter H, Penn‐Nicholson A, Toefy A, Erasmus M, Hanekom WA, Scriba TJ, Lai RP, Marais S, Fletcher HA, Meintjes G, Wilkinson RJ, Cotton MF, Pahwa S, Cameron MJ, Nemes E. Host transcriptomic signatures of tuberculosis can predict immune reconstitution inflammatory syndrome in HIV patients. Eur J Immunol 2022; 52:1112-1119. [PMID: 35398886 PMCID: PMC9276552 DOI: 10.1002/eji.202249815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 04/06/2022] [Accepted: 04/07/2022] [Indexed: 12/13/2022]
Abstract
Immune reconstitution inflammatory syndrome (IRIS) can be a complication of antiretroviral therapy (ART) in patients with advanced HIV, but its pathogenesis is uncertain. In tuberculosis (TB) endemic countries, IRIS is often associated with mycobacterial infections or Bacille-Calmette-Guerin (BCG) vaccination in children. With no predictive or confirmatory tests at present, IRIS remains a diagnosis of exclusion. We tested whether RISK6 and Sweeney3, validated immune-based blood transcriptomic signatures for TB, could predict or diagnose IRIS in HIV+ children and adults. Transcripts were measured by RT-qPCR in BCG-vaccinated children and by microarray in HIV+ adults with TB including TB meningitis (TBM). Signature scores before ART initiation and up to IRIS diagnosis were compared between participants who did or did not develop IRIS. In children, RISK6 and Sweeney3 discriminated IRIS cases from non-IRIS controls before ART, and at diagnosis. In adults with TB, RISK6 discriminated IRIS cases from controls after half-week on ART and at TB-IRIS onset. In adults with TBM, only Sweeney3 discriminated IRIS cases from controls before ART, while both signatures distinguished cases from controls at TB-IRIS onset. Parsimonious whole blood transcriptomic signatures for TB showed potential to predict and diagnose IRIS in HIV+ children and adults.
Collapse
Affiliation(s)
- Stanley Kimbung Mbandi
- South African Tuberculosis Vaccine Initiative (SATVI)Institute of Infectious Disease and Molecular Medicine and Division of ImmunologyDepartment of PathologyUniversity of Cape TownCape TownSouth Africa
| | - Hannah Painter
- Department of Infection BiologyLondon School of Hygiene & Tropical MedicineLondonUK
| | - Adam Penn‐Nicholson
- South African Tuberculosis Vaccine Initiative (SATVI)Institute of Infectious Disease and Molecular Medicine and Division of ImmunologyDepartment of PathologyUniversity of Cape TownCape TownSouth Africa
| | - Asma Toefy
- South African Tuberculosis Vaccine Initiative (SATVI)Institute of Infectious Disease and Molecular Medicine and Division of ImmunologyDepartment of PathologyUniversity of Cape TownCape TownSouth Africa
| | - Mzwandile Erasmus
- South African Tuberculosis Vaccine Initiative (SATVI)Institute of Infectious Disease and Molecular Medicine and Division of ImmunologyDepartment of PathologyUniversity of Cape TownCape TownSouth Africa
| | - Willem A. Hanekom
- South African Tuberculosis Vaccine Initiative (SATVI)Institute of Infectious Disease and Molecular Medicine and Division of ImmunologyDepartment of PathologyUniversity of Cape TownCape TownSouth Africa
| | - Thomas J. Scriba
- South African Tuberculosis Vaccine Initiative (SATVI)Institute of Infectious Disease and Molecular Medicine and Division of ImmunologyDepartment of PathologyUniversity of Cape TownCape TownSouth Africa
| | - Rachel P.J. Lai
- Department of Infectious DiseasesImperial College LondonLondonUK
| | - Suzaan Marais
- Wellcome Centre for Infectious Diseases Research in AfricaUniversity of Cape TownObservatorySouth Africa
- Institute of Infectious Disease and Molecular Medicine and Department of MedicineUniversity of Cape TownObservatorySouth Africa
| | - Helen A. Fletcher
- Department of Infection BiologyLondon School of Hygiene & Tropical MedicineLondonUK
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in AfricaUniversity of Cape TownObservatorySouth Africa
- Institute of Infectious Disease and Molecular Medicine and Department of MedicineUniversity of Cape TownObservatorySouth Africa
| | - Robert J. Wilkinson
- Department of Infectious DiseasesImperial College LondonLondonUK
- Wellcome Centre for Infectious Diseases Research in AfricaUniversity of Cape TownObservatorySouth Africa
- Institute of Infectious Disease and Molecular Medicine and Department of MedicineUniversity of Cape TownObservatorySouth Africa
- Francis Crick InstituteLondonUK
| | - Mark F. Cotton
- Family Center for Research with UbuntuDepartment of Pediatrics & Child HealthFaculty of Medicine and Health SciencesStellenbosch UniversityTygerbergSouth Africa
| | - Savita Pahwa
- Department of Microbiology and ImmunologyMiami Center for AIDS ResearchUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Mark J. Cameron
- Department of Population & Quantitative Health SciencesCase Western Reserve University School of MedicineClevelandOhioUSA
| | - Elisa Nemes
- South African Tuberculosis Vaccine Initiative (SATVI)Institute of Infectious Disease and Molecular Medicine and Division of ImmunologyDepartment of PathologyUniversity of Cape TownCape TownSouth Africa
| |
Collapse
|
18
|
Zhao Y, Hohlfeld A, Namale P, Meintjes G, Maartens G, Engel ME. Risk of Immune Reconstitution Inflammatory Syndrome With Integrase Inhibitors Versus Other Classes of Antiretrovirals: A Systematic Review and Meta-analysis of Randomized Trials. J Acquir Immune Defic Syndr 2022; 90:232-239. [PMID: 35175970 PMCID: PMC7612870 DOI: 10.1097/qai.0000000000002937] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/02/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Integrase strand transfer inhibitors (InSTIs) decrease HIV plasma viral load faster than other antiretroviral classes. More rapid viral load decline has been associated with higher risk of immune reconstitution inflammatory syndrome (IRIS). There are conflicting reports on the association between InSTI and IRIS. We performed a systematic review and meta-analysis to compare the risk of IRIS among treatment-naive HIV-positive patients starting InSTI versus non-InSTI regimens. METHODS We searched PubMed, Scopus, Web of Science, Africa-Wide, and Cochrane databases from earliest available date to 26 November 2021, for randomized controlled trials (RCTs) having intervention arms with InSTI versus control arms without InSTI in patients initiating first-line antiretroviral therapy. The primary outcome was relative risk (RR) of IRIS, whereas the secondary outcome was RR of paradoxical tuberculosis-associated IRIS (TB-IRIS). Data were combined by random-effects meta-analysis according to the Mantel-Haenszel method. The protocol for this study is registered with PROSPERO, CRD42020213976. RESULTS We included 14 RCTs comprising 8696 participants from 6 continents for the primary outcome of IRIS and a subset of 674 participants (from 3 RCTs) for the secondary outcome of paradoxical TB-IRIS. Risk of IRIS was similar between InSTI and non-InSTI regimens (RR, 0.93; 95% confidence interval: 0.75 to 1.14). There was a trend towards a lower risk of paradoxical TB-IRIS with InSTI versus efavirenz regimens that was not statistically significant (RR, 0.64; 95% confidence interval: 0.34 to 1.19). CONCLUSIONS In this meta-analysis among treatment-naive patients commencing first-line antiretroviral therapy, InSTI regimens were not associated with higher risk of IRIS.
Collapse
Affiliation(s)
- Ying Zhao
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Ameer Hohlfeld
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - Phiona Namale
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Mark E Engel
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
19
|
Medical Care for Tuberculosis-HIV-Coinfected Patients in Russia with Respect to a Changeable Patients’ Structure. Trop Med Infect Dis 2022; 7:tropicalmed7060086. [PMID: 35736965 PMCID: PMC9228798 DOI: 10.3390/tropicalmed7060086] [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: 04/07/2022] [Revised: 05/26/2022] [Accepted: 05/29/2022] [Indexed: 01/25/2023] Open
Abstract
To date, tuberculosis (TB) remains the primary cause of mortality in human immunodeficiency virus (HIV) patients in Russia. Since the beginning of 2000, a sharp change in the HIV patients’ structure, to the main known risk factors for HIV infection has taken place in Russia. The transmission of HIV through injectable drug use has begun to decline significantly, giving way to the prevalence of sexual HIV transmission today. These changes may require adjustments to organizational approaches to anti-TB care and the treatment of HIV-positive patients. Our study is aimed at identifying changes in TB-HIV coinfection patients’ structures in 2019 compared to 2000. Based on the results obtained, our goal was to point out the parameters that need to be taken into account when developing approaches to improve the organization of TB control care for people with HIV infection. We have carried out a cross-sectional, retrospective, epidemiological study using government TB registry data from four regions in two federal districts of Russia in 2019. The case histories of 2265 patients from two regions with high HIV prevalence, which are part of the Siberian Federal District of Russia, and 89 patient histories from two regions of low HIV prevalence, which are part of the Central Federal District of Russia, were analyzed. We found that parenteral transmission (69.4%) remains the primary route of HIV transmission among the TB-HIV coinfected. The unemployed of working age without disability account for 80.2% of all coinfected people, while the formerly incarcerated account for 53.7% and the homeless account for 4.1%. Those with primary multidrug-resistant TB (MDR-TB) comprise 56.2% of HIV-TB patients. When comparing the incidence of coinfection with HIV among TB patients, statistically significant differences were obtained. Thus, the chances of coinfection increased by 4.33 times among people with active TB (95% CI: 2.31; 8.12), by 2.97 times among people with MDR-TB (95% CI: 1.66; 5.32), by 5.2 times in people with advanced processes in the lungs, including destruction, (95% CI: 2.78; 9.7), as well as by 10.3 times in the case of death within the first year after the TB diagnosis (95% CI: 2.99; 35.5). The absence of data for the presence of TB during preventive examination was accompanied by a decrease in the chances of detecting coinfection (OR 0.36; 95% CI: 0.2; 0.64). We have identified the probable causes of the high incidence of TB among HIV-infected: HIV-patient social maladaptation usually results in delayed medical care, leading to TB treatment regimen violations. Furthermore, self-administration of drugs triggers MDR-TB within this group. Healthcare providers should clearly explain to patients the critical importance of immediately seeking medical care when initial TB symptoms appear.
Collapse
|
20
|
Nakamura S, Muramae N, Fujisawa A, Yasuda N, Okano M, Mori K, Otsui K, Sakaguchi K. Hemophagocytic Syndrome-Like Tuberculosis-Immune Reconstitution Inflammatory Syndrome After the Initiation of Hepatic Tuberculosis Treatment. Cureus 2022; 14:e24644. [PMID: 35663666 PMCID: PMC9156395 DOI: 10.7759/cureus.24644] [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] [Accepted: 05/01/2022] [Indexed: 11/26/2022] Open
Abstract
A 25-year-old Nepalese woman was referred to our hospital because of fever and intermittent abdominal pain with inguinal lymphadenopathy, which had lasted for several months. A liver biopsy of the positron emission tomography-positive lesion led to a diagnosis of hepatic tuberculosis. After the initiation of antituberculosis treatment, her symptoms resolved. However, 11 days after treatment initiation, chest and back pain, high-grade fever, and vomiting appeared and gradually worsened. She developed anemia and her serum ferritin level was elevated. Hemophagocytic syndrome due to the initial deterioration of tuberculosis was suspected and steroid therapy was initiated with the continuation of the antituberculosis drugs. Thereafter, the patient’s condition improved remarkably.
Collapse
|
21
|
van de Water BJ, Fulcher I, Cilliers S, Meyer N, Wilson M, Young C, Gaunt B, le Roux K. Association of HIV infection and antiretroviral therapy with the occurrence of an unfavorable TB treatment outcome in a rural district hospital in Eastern Cape, South Africa: A retrospective cohort study. PLoS One 2022; 17:e0266082. [PMID: 35381042 PMCID: PMC8982869 DOI: 10.1371/journal.pone.0266082] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 03/15/2022] [Indexed: 11/23/2022] Open
Abstract
Background Our objective was to assess differences in TB treatment outcomes between individuals who were HIV negative, HIV positive on anti-retroviral treatment (ART) and HIV positive not on ART, at TB treatment initiation at a rural district hospital in Eastern Cape, South Africa. Methods This was a retrospective cohort study of individuals diagnosed with TB between January 2017 and April 2020 at a district hospital. Adults 15 years and over with reported HIV status and treatment outcome were included (N = 711). A categorical outcome with three levels was considered: unfavorable, down referral, and success. We report descriptive statistics for the association between HIV and ART status and treatment outcome using Chi-square and Fisher’s exact tests. A multinomial baseline logit model was used to estimate odds ratios for treatment outcomes. Results Overall, 59% of included patients were HIV positive with 75% on ART. Eighty-eight patients 12% had an unfavorable outcome. Half of all patients were down referred with an additional 37% having a successful outcome. Individuals without HIV were more likely to be down referred (versus unfavorable) compared to individuals with untreated HIV (2.90 OR, 1.36, 6.17 95% CI). There was a greater likelihood for individuals without HIV having a successful TB treatment outcome compared to individuals with untreated HIV (4.98 OR, 2.07, 11.25 95% CI). Conclusion The majority of individuals had positive TB treatment outcomes (down referred or success). However, people without HIV had nearly five times greater odds of having successful outcomes than those with untreated HIV.
Collapse
Affiliation(s)
| | - Isabel Fulcher
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
| | - Suretha Cilliers
- Zithulele District Hospital, Mqanduli, Eastern Cape, South Africa
| | - Nadishani Meyer
- Zithulele District Hospital, Mqanduli, Eastern Cape, South Africa
| | - Michael Wilson
- Advance Access & Delivery, Durban, Kwa-Zulu Natal, South Africa
| | - Catherine Young
- Jabulani Rural Health Foundation, Mqanduli, Eastern Cape, South Africa
| | - Ben Gaunt
- Zithulele District Hospital, Mqanduli, Eastern Cape, South Africa
- Family Medicine Department, Walter Sisulu University, Mthatha, Eastern Cape, South Africa
| | - Karl le Roux
- Zithulele District Hospital, Mqanduli, Eastern Cape, South Africa
- Family Medicine Department, Walter Sisulu University, Mthatha, Eastern Cape, South Africa
- Primary Health Care Directorate, University of Cape Town, Cape Town, Western Cape, South Africa
| |
Collapse
|
22
|
Hosomi S, Sugita N, Kanamori A, Ominami M, Otani K, Kamata N, Tanaka F, Nagami Y, Taira K, Fujiwara Y. A case of paradoxical response during anti-tuberculosis treatment in a patient with ulcerative colitis. Clin J Gastroenterol 2022; 15:592-597. [PMID: 35244861 DOI: 10.1007/s12328-022-01616-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 02/21/2022] [Indexed: 11/29/2022]
Abstract
Emerging anti-tumor necrosis factor (TNF)-α antibodies therapy changed treatment strategy to inflammatory bowel diseases because of the efficacy. However, TNF-α inhibitor can be associated with an increased risk of infectious complications, especially tuberculosis. A 71-year-old female with steroid-dependent ulcerative colitis (UC) was admitted due to relapse of UC with endoscopically severe active. Golimumab and adjunctive prednisolone started with 30 mg daily resulted in clinical remission. However, she had general fatigue and fever at the time of seventh injection of golimumab without abdominal symptoms. Based on positive interferon-gamma release assay, polymerase chain reaction positive for tuberculosis (TB) in pleural fluid, and chest computed tomography, she was diagnosed as tuberculous pleuritis. Standard anti-TB treatment (isoniazid, rifampicin, ethambutol, and pyrazinamide) was started without cessation of golimumab, because cessation of TNF-α inhibitors during anti-TB treatment could cause the paradoxical response by skewing from regulatory to inflammatory immune responses. However, four weeks after initiation of anti-TB treatment, she got fever-up and pleural effusion increased. We then started prednisolone 30 mg daily as diagnosis of paradoxical response, resulting in improving the symptoms. This is a suggestive case of paradoxical response during anti-TB treatment despite continuous TNF-α inhibitors.
Collapse
Affiliation(s)
- Shuhei Hosomi
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.
| | - Naoko Sugita
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Atsushi Kanamori
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Masaki Ominami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Koji Otani
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Noriko Kamata
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Fumio Tanaka
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Yasuaki Nagami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Koichi Taira
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Yasuhiro Fujiwara
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| |
Collapse
|
23
|
Immunopathogenesis in HIV-associated pediatric tuberculosis. Pediatr Res 2022; 91:21-26. [PMID: 33731810 PMCID: PMC8446109 DOI: 10.1038/s41390-021-01393-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 11/25/2020] [Accepted: 01/18/2021] [Indexed: 11/09/2022]
Abstract
Tuberculosis (TB) is an increasing global emergency in human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) patients, in which host immunity is dysregulated and compromised. However, the pathogenesis and efficacy of therapeutic strategies in HIV-associated TB in developing infants are essentially lacking. Bacillus Calmette-Guerin vaccine, an attenuated live strain of Mycobacterium bovis, is not adequately effective, which confers partial protection against Mycobacterium tuberculosis (Mtb) in infants when administered at birth. However, pediatric HIV infection is most devastating in the disease progression of TB. It remains challenging whether early antiretroviral therapy (ART) could maintain immune development and function, and restore Mtb-specific immune function in HIV-associated TB in children. A better understanding of the immunopathogenesis in HIV-associated pediatric Mtb infection is essential to provide more effective interventions, reducing the risk of morbidity and mortality in HIV-associated Mtb infection in infants. IMPACT: Children living with HIV are more likely prone to opportunistic infection, predisposing high risk of TB diseases. HIV and Mtb coinfection in infants may synergistically accelerate disease progression. Early ART may probably induce immune reconstitution inflammatory syndrome and TB pathology in HIV/Mtb coinfected infants.
Collapse
|
24
|
Nosik M, Ryzhov K, Rymanova I, Sobkin A, Kravtchenko A, Kuimova U, Pokrovsky V, Zverev V, Svitich O. Dynamics of Plasmatic Levels of Pro- and Anti-Inflammatory Cytokines in HIV-Infected Individuals with M. tuberculosis Co-Infection. Microorganisms 2021; 9:microorganisms9112291. [PMID: 34835417 PMCID: PMC8624412 DOI: 10.3390/microorganisms9112291] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 10/24/2021] [Accepted: 11/02/2021] [Indexed: 12/27/2022] Open
Abstract
Tuberculosis (TB) and HIV have profound effects on the immune system, which can lead to the activation of viral replication and negatively regulate the activation of T cells. Dysregulation in the production of cytokines necessary to fight HIV and M. tuberculosis may ultimately affect the results of the treatment and be important in the pathogenesis of HIV infection and TB. This work presents the results of a study of the expression of pro- and anti-inflammatory cytokines (IFN-γ, TNF-α, IL-2, IL-4, IL-6, IL-10, IL-1RA) in drug-naïve patients with dual infection of HIV/TB at the late stages of HIV-infection, with newly diagnosed HIV and TB, and previously untreated HIV in the process of receiving antiretroviral (ART) and TB treatment vs. a cohort of patients with HIV monoinfection and TB monoinfection. The study revealed that during a double HIV/TB infection, both Th1 and Th2 immune responses are suppressed, and a prolonged dysregulation of the immune response and an increased severity of the disease in pulmonary/extrapulmonary tuberculosis is observed in HIV/TB co-infection. Moreover, it was revealed that a double HIV/TB infection is characterized by delayed and incomplete recovery of immune activity. High levels of IL-6 were detected in patients with HIV/TB co-infection before initiation of dual therapy (2.1-fold increase vs. HIV), which persisted even after 6 months of treatment (8.96-fold increase vs. HIV), unlike other cytokines. The persistent enhanced expression of IL-6 in patients with dual HIV/TB co-infection allows the consideration of it as a potential marker of early detection of M. tuberculosis infection in HIV-infected individuals. The results of multivariate regression analysis showed a statistical trend towards an increase in the incidence of IRIS in patients with high IL-1Ra levels (in the range of 1550–2500 pg/mL): OR = 4.3 (95%CI 3.7–14.12, p = 0.53), which also allows IL-1Ra to be considered as a potential predictive biomarker of the development of TB-IRIS and treatment outcomes.
Collapse
Affiliation(s)
- Marina Nosik
- I.I. Mechnikov Institute of Vaccine and Sera, 105064 Moscow, Russia; (K.R.); (V.Z.); (O.S.)
- Correspondence:
| | - Konstantin Ryzhov
- I.I. Mechnikov Institute of Vaccine and Sera, 105064 Moscow, Russia; (K.R.); (V.Z.); (O.S.)
| | - Irina Rymanova
- G.A. Zaharyan Moscow Tuberculosis Clinic, Department for Treatment of TB Patients with HIV Infection, 125466 Moscow, Russia; (I.R.); (A.S.)
| | - Alexandr Sobkin
- G.A. Zaharyan Moscow Tuberculosis Clinic, Department for Treatment of TB Patients with HIV Infection, 125466 Moscow, Russia; (I.R.); (A.S.)
| | - Alexey Kravtchenko
- Central Research Institute of Epidemiology, 111123 Moscow, Russia; (A.K.); (U.K.); (V.P.)
| | - Ulyana Kuimova
- Central Research Institute of Epidemiology, 111123 Moscow, Russia; (A.K.); (U.K.); (V.P.)
| | - Vadim Pokrovsky
- Central Research Institute of Epidemiology, 111123 Moscow, Russia; (A.K.); (U.K.); (V.P.)
| | - Vitaly Zverev
- I.I. Mechnikov Institute of Vaccine and Sera, 105064 Moscow, Russia; (K.R.); (V.Z.); (O.S.)
| | - Oxana Svitich
- I.I. Mechnikov Institute of Vaccine and Sera, 105064 Moscow, Russia; (K.R.); (V.Z.); (O.S.)
| |
Collapse
|
25
|
Nacarapa E, Verdu ME, Nacarapa J, Macuacua A, Chongo B, Osorio D, Munyangaju I, Mugabe D, Paredes R, Chamarro A, Revollo B, Alexandre SS, Simango M, Torrus D, Ramos-Rincon JM. Predictors of attrition among adults in a rural HIV clinic in southern Mozambique: 18-year retrospective study. Sci Rep 2021; 11:17897. [PMID: 34504234 PMCID: PMC8429703 DOI: 10.1038/s41598-021-97466-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 08/18/2021] [Indexed: 11/09/2022] Open
Abstract
HIV remains a major cause of morbidity and mortality for people living in many low-income countries. With an HIV prevalence of 12.4% among people aged over 15 years, Mozambique was ranked in 2019 as one of eight countries with the highest HIV rates in the world. We analyzed routinely collected data from electronical medical records in HIV-infected patients aged 15 years or older and enrolled at Carmelo Hospital of Chokwe in Chokwe from 2002 to 2019. Attrition was defined as individuals who were either reported dead or lost to follow-up (LTFU) (≥ 90 days since the last clinic visit with missed medical pick-up after 3 days of failed calls). Kaplan–Meier survival curves and Cox regression analyses were used to model the incidence and predictors of time to attrition. From January 2002 to December 2019, 16,321 patients were enrolled on antiretroviral therapy (ART): 59.2% were women, and 37.9% were aged 25–34 years old. At the time of the analysis, 7279 (44.6%) were active and on ART. Overall, the 16,321 adults on ART contributed a total of 72,987 person-years of observation. The overall attrition rate was 9.46 per 100 person-years. Cox regression showed a higher risk of attrition in those following an inpatient regimen (hazard ratio [HR] 3.18, 95% confidence interval [CI] 2.89–3.50; p < 0.001), having CD4 counts under 50 cells/µL (HR 1.91, 95% CI 1.63–2.24, p < 0.001), receiving anti-TB treatment within 90 days of ART initiation (HR 6.53, 95% CI 5.72–7.45; p < 0.001), classified as WHO clinical stage III (HR 3.75, 95% CI 3.21–4.37; p < 0.001), and having Kaposi’s sarcoma (HR 1.99, 95% CI 1.65–2.39, p < 0.001). Kaplan–Meier analysis showed that patients with CD4 counts of less than 50 cells/µL on ART initiation had a 40% lower chance of survival at 18 years. Low CD4 cell counts, ART initiation as an inpatient, WHO clinical stage III, and anti-tuberculosis treatment within 90 days of ART initiation were strongly associated with attrition. Strengthening HIV testing and ART treatment, improving the diagnosis of tuberculosis before ART initiation, and guaranteed psychosocial support systems are the best tools to reduce patient attrition after starting ART.
Collapse
Affiliation(s)
- Edy Nacarapa
- Carmelo Hospital of Chókwè - The Daughters of Charity, Saint Vicente of Paul, TB/HIV Division, Avenida Trabalho, Chokwé, Gaza Province, Mozambique.,Tinpswalo Association, Vincentian Association to Fight AIDS and TB, Research Unit, Chókwè, Gaza Province, Mozambique
| | - M Elisa Verdu
- Carmelo Hospital of Chókwè - The Daughters of Charity, Saint Vicente of Paul, TB/HIV Division, Avenida Trabalho, Chokwé, Gaza Province, Mozambique
| | - Joana Nacarapa
- Carmelo Hospital of Chókwè - The Daughters of Charity, Saint Vicente of Paul, TB/HIV Division, Avenida Trabalho, Chokwé, Gaza Province, Mozambique.,Tinpswalo Association, Vincentian Association to Fight AIDS and TB, Research Unit, Chókwè, Gaza Province, Mozambique
| | - Artur Macuacua
- Carmelo Hospital of Chókwè - The Daughters of Charity, Saint Vicente of Paul, TB/HIV Division, Avenida Trabalho, Chokwé, Gaza Province, Mozambique
| | - Bartolomeu Chongo
- Carmelo Hospital of Chókwè - The Daughters of Charity, Saint Vicente of Paul, TB/HIV Division, Avenida Trabalho, Chokwé, Gaza Province, Mozambique
| | | | - Isabelle Munyangaju
- Tinpswalo Association, Vincentian Association to Fight AIDS and TB, Research Unit, Chókwè, Gaza Province, Mozambique
| | | | - Roger Paredes
- IrsiCaixa - Institute of AIDS Research, Barcelona, Spain.,FLS Foundation - Fight AIDS Foundation, Barcelona, Spain
| | - Ana Chamarro
- FLS Foundation - Fight AIDS Foundation, Barcelona, Spain
| | - Boris Revollo
- FLS Foundation - Fight AIDS Foundation, Barcelona, Spain
| | | | | | - Diego Torrus
- Department of Internal Medicine, University General Hospital of Alicante and Miguel Hernandez University, Elche, Spain
| | - Jose-Manuel Ramos-Rincon
- Department of Internal Medicine, University General Hospital of Alicante and Miguel Hernandez University, Elche, Spain.
| |
Collapse
|
26
|
Weber MR, Fehr JS, Kuhn FP, Kaelin MB. Approach for tuberculosis-associated immune reconstitution inflammatory syndrome in an HIV-negative patient. BMJ Case Rep 2021; 14:14/8/e232639. [PMID: 34404638 PMCID: PMC8375722 DOI: 10.1136/bcr-2019-232639] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A male refugee from the Middle East was diagnosed with pulmonary tuberculosis and Pott’s disease with paravertebral abscess. After starting the standard regimen, the sputum culture converted to negative and the patient’s general condition improved. Six weeks later, the patient presented with clinical worsening of known symptoms, new appearance of focal neurological deficits and progress of radiological features showing progression of the paravertebral abscess. Immune reconstitution inflammatory syndrome with Mycobacterium tuberculosis (TB-IRIS) was presumed, and treatment with high-dose steroids was started. Due to recurrent relapses while tapering, corticosteroids had to be given over a prolonged period. After treatment completion, the patient was in a good general condition, abscesses had decreased and neurological deficits were in complete remission. This case presents the rare manifestation of TB-IRIS in HIV-negative patients and its management in a high-income country.
Collapse
Affiliation(s)
| | - Jan Sven Fehr
- Divison of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | | | - Marisa Brigitta Kaelin
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
27
|
Owens DR, Medalla CM, Brown KN, Wijewardena K, Thomas CP, Iro MA, Jones CE, Faust SN, Patel SV. Problem-solving in clinical practice: Persisting respiratory distress in a premature infant. Arch Dis Child Educ Pract Ed 2021; 106:239-243. [PMID: 33077533 DOI: 10.1136/archdischild-2019-317757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 07/12/2020] [Accepted: 08/28/2020] [Indexed: 11/03/2022]
Abstract
The deterioration of a previously stable preterm infant is a common scenario on the neonatal unit. The the most common bacterial causes of deterioration are nosocomial infections, such as coagulase-negative Staphylococcus and Staphylococcus aureus Non-infective conditions such as pulmonary haemorrhage, anaemia of prematurity and necrotising enterocolitis may also cause preterm infants to deteriorate. This case chronicles the unusual diagnostic journey of an infant born at 27+1 weeks who deteriorated at 26 days of life and did not respond to antimicrobial therapy as anticipated.
Collapse
Affiliation(s)
- Daniel R Owens
- NIHR Southampton Clinical Research Facility and NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | | | - Kelly N Brown
- Department of Neonatal Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Kishani Wijewardena
- Department of Child Health, Hampshire Hospitals NHS Foundation Trust, Basingstoke, Hampshire, UK
| | - Claire P Thomas
- Department of Clinical Microbiology/Infection, Hampshire Hospitals NHS Foundation Trust, Basingstoke, Hampshire, UK
| | - Mildred A Iro
- Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK.,Paediatric Infectious Diseases and Immunology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Christine E Jones
- NIHR Southampton Clinical Research Facility and NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Saul N Faust
- NIHR Southampton Clinical Research Facility and NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Sanjay Valabh Patel
- Paediatric Infectious Diseases and Immunology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| |
Collapse
|
28
|
Wang X, Mehra S, Kaushal D, Veazey RS, Xu H. Abnormal Tryptophan Metabolism in HIV and Mycobacterium tuberculosis Infection. Front Microbiol 2021; 12:666227. [PMID: 34262540 PMCID: PMC8273495 DOI: 10.3389/fmicb.2021.666227] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/31/2021] [Indexed: 12/12/2022] Open
Abstract
Host metabolism has recently gained more attention for its roles in physiological functions and pathologic conditions. Of these, metabolic tryptophan disorders generate a pattern of abnormal metabolites that are implicated in various diseases. Here, we briefly highlight the recent advances regarding abnormal tryptophan metabolism in HIV and Mycobacterium tuberculosis infection and discuss its potential impact on immune regulation, disease progression, and neurological disorders. Finally, we also discuss the potential for metabolic tryptophan interventions toward these infectious diseases.
Collapse
Affiliation(s)
- Xiaolei Wang
- Division of Comparative Pathology, Tulane National Primate Research Center, Tulane University School of Medicine, Covington, LA, United States
| | - Smriti Mehra
- Division of Comparative Pathology, Tulane National Primate Research Center, Tulane University School of Medicine, Covington, LA, United States
| | - Deepak Kaushal
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, TX, United States
| | - Ronald S. Veazey
- Division of Comparative Pathology, Tulane National Primate Research Center, Tulane University School of Medicine, Covington, LA, United States
| | - Huanbin Xu
- Division of Comparative Pathology, Tulane National Primate Research Center, Tulane University School of Medicine, Covington, LA, United States
| |
Collapse
|
29
|
Pei L, Fukutani KF, Tibúrcio R, Rupert A, Dahlstrom EW, Galindo F, Laidlaw E, Lisco A, Manion M, Andrade BB, Sereti I. Plasma Metabolomics Reveals Dysregulated Metabolic Signatures in HIV-Associated Immune Reconstitution Inflammatory Syndrome. Front Immunol 2021; 12:693074. [PMID: 34211479 PMCID: PMC8239348 DOI: 10.3389/fimmu.2021.693074] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 05/27/2021] [Indexed: 12/17/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) is an inflammatory complication associated with an underlying opportunistic infection that can be observed in HIV-infected individuals shortly after the initiation of antiretroviral therapy, despite successful suppression of HIV viral load and CD4+ T cell recovery. Better understanding of IRIS pathogenesis would allow for targeted prevention and therapeutic approaches. In this study, we sought to evaluate the metabolic perturbations in IRIS across longitudinal time points using an unbiased plasma metabolomics approach as well as integrated analyses to include plasma inflammatory biomarker profile and whole blood transcriptome. We found that many lipid and amino acid metabolites differentiated IRIS from non-IRIS conditions prior to antiretroviral therapy and during the IRIS event, implicating the association between oxidative stress, tryptophan pathway, and lipid mediated signaling and the development of IRIS. Lipid and amino acid metabolic pathways also significantly correlated with inflammatory biomarkers such as IL-12p70 and IL-8 at the IRIS event, indicating the role of cellular metabolism on cell type specific immune activation during the IRIS episode and in turn the impact of immune activation on cellular metabolism. In conclusion, we defined the metabolic profile of IRIS and revealed that perturbations in metabolism may predispose HIV-infected individuals to IRIS development and contribute to the inflammatory manifestations during the IRIS event. Furthermore, our findings expanded our current understanding IRIS pathogenesis and highlighted the significance of lipid and amino acid metabolism in inflammatory complications.
Collapse
Affiliation(s)
- Luxin Pei
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, United States.,Department of Biology, Johns Hopkins University, Baltimore, MD, United States
| | - Kiyoshi F Fukutani
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil.,Laboratory of Inflammation and Biomarkers, Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Brazil.,Curso de Medicina, Centro Universitário Faculdade de Tecnologia e Ciências (UniFTC), Salvador, Brazil
| | - Rafael Tibúrcio
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil.,Laboratory of Inflammation and Biomarkers, Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Brazil.,Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil
| | - Adam Rupert
- Leidos Biomedical Research Inc., Frederick National Laboratory for Cancer Research, Frederick, MD, United States
| | - Eric W Dahlstrom
- Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Hamilton, MT, United States
| | - Frances Galindo
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, United States
| | - Elizabeth Laidlaw
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, United States
| | - Andrea Lisco
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, United States
| | - Maura Manion
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, United States
| | - Bruno B Andrade
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil.,Laboratory of Inflammation and Biomarkers, Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Brazil.,Curso de Medicina, Centro Universitário Faculdade de Tecnologia e Ciências (UniFTC), Salvador, Brazil.,Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil.,Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Irini Sereti
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, United States
| |
Collapse
|
30
|
Stek C, Buyze J, Menten J, Schutz C, Thienemann F, Blumenthal L, Maartens G, Boyles T, Wilkinson RJ, Meintjes G, Lynen L. Diagnostic Accuracy of the INSHI Consensus Case Definition for the Diagnosis of Paradoxical Tuberculosis-IRIS. J Acquir Immune Defic Syndr 2021; 86:587-592. [PMID: 33394813 PMCID: PMC7938911 DOI: 10.1097/qai.0000000000002606] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 12/07/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The diagnosis of paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) relies on characteristic clinical features synthesized as the International Network for the Study of HIV-associated IRIS (INSHI) case definition. There is no confirmatory laboratory test. SETTING Site B HIV-TB clinic in Khayelitsha, Cape Town, South Africa. METHODS Using data of participants with HIV-associated tuberculosis starting antiretroviral treatment from a prospective trial evaluating prednisone for TB-IRIS prevention, we applied latent class analysis to model a gold standard for TB-IRIS. The model-predicted probability of TB-IRIS for each participant was used to assess the performance of the INSHI case definition and compare its diagnostic accuracy with several adapted case definitions. RESULTS Data for this analysis were complete for 217 participants; 41% developed TB-IRIS. Our latent class model included the following parameters: respiratory symptoms; night sweats; INSHI major criteria 1, 2, and 4; maximum C-reactive protein >90 mg/L; maximum heart rate >120/min; maximum temperature >37.7°C; and preantiretroviral therapy CD4 count <50 cells/µL. The model estimated a TB-IRIS incidence of 43% and had optimal goodness of fit (χ2 = 337, P = 1.0). The INSHI case definition displayed a sensitivity of 0.77 and a specificity of 0.86. Replacing all the minor INSHI criteria with objectives measures (C-reactive protein elevation, fever, and/or tachycardia) resulted in a definition with better diagnostic accuracy, with a sensitivity of 0.89 and a specificity of 0.88. CONCLUSION The INSHI case definition identifies TB-IRIS with reasonable accuracy. Amending the case definition by replacing INSHI minor criteria with objective variables improved sensitivity without loss of specificity.
Collapse
Affiliation(s)
- Cari Stek
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Wellcome Centre for Infectious Diseases Research in 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
| | - Jozefien Buyze
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Joris Menten
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Charlotte Schutz
- Wellcome Centre for Infectious Diseases Research in 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
| | - Friedrich Thienemann
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Lisette Blumenthal
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Wellcome Centre for Infectious Diseases Research in 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
| | - Tom Boyles
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Robert J. Wilkinson
- Wellcome Centre for Infectious Diseases Research in 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
- Department of Medicine, Imperial College London, London, United Kingdom; and
- The Francis Crick Institute, London, United Kingdom
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in 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
| | - Lutgarde Lynen
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| |
Collapse
|
31
|
Keeley AJ, Parkash V, Tunbridge A, Greig J, Collini P, McKane W, Tattersall RS. Anakinra in the treatment of protracted paradoxical inflammatory reactions in HIV-associated tuberculosis in the United Kingdom: a report of two cases. Int J STD AIDS 2021; 31:808-812. [PMID: 32631210 PMCID: PMC7590809 DOI: 10.1177/0956462420915394] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Paradoxical reactions, including immune reconstitution inflammatory syndrome (IRIS), are common in patients co-infected with human immunodeficiency virus (HIV) and tuberculosis (TB). Paradoxical reactions may confer substantial morbidity and mortality, especially in cases of central nervous system (CNS) TB, or through protracted usage of corticosteroids. No high-quality evidence is available to guide management in this scenario. Interleukin-1-mediated inflammation has been implicated in the pathophysiology of TB-IRIS. We describe two cases where anakinra (human recombinant interleukin-1 receptor antagonist) was used as steroid-sparing therapy for life-threatening protracted paradoxical inflammation in HIV-associated TB. In the first case of disseminated TB with lymphadenitis, protracted TB-IRIS led to amyloid A amyloidosis and nephrotic syndrome. In the second case of disseminated TB with cerebral tuberculomata, paradoxical inflammation caused unstable tuberculomata leading to profound neuro-disability. In both cases, paradoxical inflammation persisted for over a year. Protracted high-dose corticosteroid use led to adverse events yet failed to control inflammatory pathology. In both patients, anakinra successfully controlled paradoxical inflammation and facilitated withdrawal of corticosteroid therapy. Following anakinra therapy, nephrotic syndrome and neuro-disability resolved, respectively. Anakinra therapy for protracted paradoxical inflammation in HIV-associated TB may be a viable therapeutic option and warrants further research.
Collapse
Affiliation(s)
- Alexander J Keeley
- Department of Infection, Immunity and Cardiovascular Disease and Florey Institute, University of Sheffield, Sheffield, UK
| | - Vivak Parkash
- Department of Infection and Tropical Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Anne Tunbridge
- Department of Infection and Tropical Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Julia Greig
- Department of Infection and Tropical Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Paul Collini
- Department of Infection, Immunity and Cardiovascular Disease and Florey Institute, University of Sheffield, Sheffield, UK
| | - William McKane
- Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rachel S Tattersall
- Department of Rheumatology, Sheffield Teaching Hospitals NHS Foundation Trust and Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| |
Collapse
|
32
|
Abstract
Tuberculosis (TB) remains a leading cause of morbidity and mortality among people living with HIV. HIV-associated TB disproportionally affects African countries, particularly vulnerable groups at risk for both TB and HIV. Currently available TB diagnostics perform poorly in people living with HIV; however, new diagnostics such as Xpert Ultra and lateral flow urine lipoarabinomannan assays can greatly facilitate diagnosis of TB in people living with HIV. TB preventive treatment has been underutilized despite its proven benefits independent of antiretroviral therapy (ART). Shorter regimens using rifapentine can support increased availability and scale-up. Mortality is high in people with HIV-associated TB, and timely initiation of ART is critical. Programs should provide decentralized and integrated TB and HIV care in settings with high burden of both diseases to improve access to services that diagnose TB and HIV as early as possible. The new prevention and diagnosis tools recently recommended by WHO offer an immense opportunity to advance our fight against HIV-associated TB. They should be made widely available and scaled up rapidly supported by adequate funding with robust monitoring of the uptake to advance global TB elimination.
Collapse
Affiliation(s)
- Yohhei Hamada
- Centre for International Cooperation and Global TB Information, 46635Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Tokyo, Japan.,Institute for Global Health, 4919University College London, London, UK
| | - Haileyesus Getahun
- Department of Global Coordination and Partnership on Antimicrobial Resistance, 3489WHO, Geneva, Switzerland
| | - Birkneh Tilahun Tadesse
- Department of Global Coordination and Partnership on Antimicrobial Resistance, 3489WHO, Geneva, Switzerland
| | - Nathan Ford
- Department of Paediatrics, College of Medicine and Health Sciences, 128167Hawassa University, Hawassa, Ethiopia
| |
Collapse
|
33
|
Wang Y, Lin X, Wen Y. Organizing pneumonia-presenting acute respiratory distress syndrome because of paradoxical tuberculosis-immune reconstitution disease? AIDS 2021; 35:351-354. [PMID: 33394677 DOI: 10.1097/qad.0000000000002752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Yu Wang
- Department of Infectious Diseases
| | - XuYong Lin
- Pathology Department, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Ying Wen
- Department of Infectious Diseases
| |
Collapse
|
34
|
Vinhaes CL, Araujo-Pereira M, Tibúrcio R, Cubillos-Angulo JM, Demitto FO, Akrami KM, Andrade BB. Systemic Inflammation Associated with Immune Reconstitution Inflammatory Syndrome in Persons Living with HIV. Life (Basel) 2021; 11:life11010065. [PMID: 33477581 PMCID: PMC7831327 DOI: 10.3390/life11010065] [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: 11/16/2020] [Revised: 01/13/2021] [Accepted: 01/14/2021] [Indexed: 12/19/2022] Open
Abstract
Antiretroviral therapy (ART) has represented a major advancement in the care of people living with HIV (PLWHH), resulting in significant reductions in morbidity and mortality through immune reconstitution and attenuation of homeostatic disruption. Importantly, restoration of immune function in PLWH with opportunistic infections occasionally leads to an intense and uncontrolled cytokine storm following ART initiation known as immune reconstitution inflammatory syndrome (IRIS). IRIS occurrence is associated with the severe and rapid clinical deterioration that results in significant morbidity and mortality. Here, we detail the determinants underlying IRIS development in PLWH, compiling the available knowledge in the field to highlight details of the inflammatory responses in IRIS associated with the most commonly reported opportunistic pathogens. This review also highlights gaps in the understanding of IRIS pathogenesis and summarizes therapeutic strategies that have been used for IRIS.
Collapse
Affiliation(s)
- Caian L. Vinhaes
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador 40296-710, Brazil; (C.L.V.); (M.A.-P.); (R.T.); (J.M.C.-A.); (K.M.A.)
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador 40210-320, Brazil;
- Bahiana School of Medicine and Public Health, Bahia Foundation for the Development of Sciences, Salvador 40290-000, Brazil
| | - Mariana Araujo-Pereira
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador 40296-710, Brazil; (C.L.V.); (M.A.-P.); (R.T.); (J.M.C.-A.); (K.M.A.)
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador 40210-320, Brazil;
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador 40110-100, Brazil
| | - Rafael Tibúrcio
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador 40296-710, Brazil; (C.L.V.); (M.A.-P.); (R.T.); (J.M.C.-A.); (K.M.A.)
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador 40210-320, Brazil;
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador 40110-100, Brazil
| | - Juan M. Cubillos-Angulo
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador 40296-710, Brazil; (C.L.V.); (M.A.-P.); (R.T.); (J.M.C.-A.); (K.M.A.)
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador 40210-320, Brazil;
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador 40110-100, Brazil
| | - Fernanda O. Demitto
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador 40210-320, Brazil;
| | - Kevan M. Akrami
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador 40296-710, Brazil; (C.L.V.); (M.A.-P.); (R.T.); (J.M.C.-A.); (K.M.A.)
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador 40210-320, Brazil;
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador 40110-100, Brazil
- Divisions of Infectious Diseases and Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California, San Diego, CA 92093, USA
| | - Bruno B. Andrade
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador 40296-710, Brazil; (C.L.V.); (M.A.-P.); (R.T.); (J.M.C.-A.); (K.M.A.)
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador 40210-320, Brazil;
- Bahiana School of Medicine and Public Health, Bahia Foundation for the Development of Sciences, Salvador 40290-000, Brazil
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador 40110-100, Brazil
- Curso de Medicina, Centro Universitário Faculdade de Tecnologia e Ciências (UniFTC), Salvador 41741-590, Brazil
- Correspondence: ; Tel.: +55-71-3176-2264
| |
Collapse
|
35
|
Walker NF, Opondo C, Meintjes G, Jhilmeet N, Friedland JS, Elkington PT, Wilkinson RJ, Wilkinson KA. Invariant Natural Killer T-cell Dynamics in Human Immunodeficiency Virus-associated Tuberculosis. Clin Infect Dis 2021; 70:1865-1874. [PMID: 31190065 PMCID: PMC7156773 DOI: 10.1093/cid/ciz501] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 06/11/2019] [Indexed: 01/04/2023] Open
Abstract
Background Tuberculosis (TB) is the leading cause of mortality and morbidity in people living with human immunodeficiency virus (HIV) infection (PLWH). PLWH with TB disease are at risk of the paradoxical TB-associated immune reconstitution inflammatory syndrome (TB-IRIS) when they commence antiretroviral therapy. However, the pathophysiology is incompletely understood and specific therapy is lacking. We investigated the hypothesis that invariant natural killer T (iNKT) cells contribute to innate immune dysfunction associated with TB-IRIS. Methods In a cross-sectional study of 101 PLWH and HIV-uninfected South African patients with active TB and controls, iNKT cells were enumerated using α-galactosylceramide-loaded CD1d tetramers and subsequently functionally characterized by flow cytometry. In a second study of 49 people with HIV type 1 (HIV-1) and active TB commencing antiretroviral therapy, iNKT cells in TB-IRIS patients and non-IRIS controls were compared longitudinally. Results Circulating iNKT cells were reduced in HIV-1 infection, most significantly the CD4+ subset, which was inversely associated with HIV-1 viral load. iNKT cells in HIV-associated TB had increased surface CD107a expression, indicating cytotoxic degranulation. Relatively increased iNKT cell frequency in patients with HIV-1 infection and active TB was associated with development of TB-IRIS following antiretroviral therapy initiation. iNKT cells in TB-IRIS were CD4+CD8– subset depleted and degranulated around the time of TB-IRIS onset. Conclusions Reduced iNKT cell CD4+ subsets as a result of HIV-1 infection may skew iNKT cell functionality toward cytotoxicity. Increased CD4– cytotoxic iNKT cells may contribute to immunopathology in TB-IRIS.
Collapse
Affiliation(s)
- Naomi F Walker
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa.,Infectious Diseases and Immunity, and Imperial College Wellcome Trust Centre for Global Health, Imperial College London, United Kingdom.,Department of Medicine, University of Cape Town, Observatory, South Africa.,Tuberculosis Centre and Department of Clinical Research
| | - Charles Opondo
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa.,Department of Medicine, University of Cape Town, Observatory, South Africa
| | - Nishtha Jhilmeet
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
| | - Jon S Friedland
- Institute of Infection and Immunity, St George's, University of London
| | - Paul T Elkington
- Infectious Diseases and Immunity, and Imperial College Wellcome Trust Centre for Global Health, Imperial College London, United Kingdom.,National Institute for Health Research Biomedical Research Centre, School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton
| | - Robert J Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa.,Department of Medicine, University of Cape Town, Observatory, South Africa.,Francis Crick Institute, London.,Department of Medicine, Imperial College London, United Kingdom
| | - Katalin A Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa.,Department of Medicine, University of Cape Town, Observatory, South Africa.,Francis Crick Institute, London
| |
Collapse
|
36
|
Maartens G, Meintjes G. Managing Human Immunodeficiency Virus-associated Tuberculosis in the Dolutegravir Era. Clin Infect Dis 2020; 70:557-558. [PMID: 30906946 DOI: 10.1093/cid/ciz259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 03/22/2019] [Indexed: 11/15/2022] Open
Affiliation(s)
- Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, South Africa
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, South Africa.,Division of Infectious Diseases and Human Immunodeficiency Virus Medicine, Department of Medicine, University of Cape Town, South Africa
| |
Collapse
|
37
|
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
|
38
|
Nabeya D, Kinjo T, Yamaniha K, Yamazato S, Tome R, Miyagi K, Nakamura H, Kinjo T, Haranaga S, Higa F, Fujita J. Use of steroids to treat anti-tumor necrosis factor α induced tuberculosis-associated immune reconstitution inflammatory syndrome: Case report and literature review. Medicine (Baltimore) 2020; 99:e22076. [PMID: 33120729 PMCID: PMC7581145 DOI: 10.1097/md.0000000000022076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Individuals with tuberculosis (TB) who are being treated with anti-tumor necrosis factor α (anti-TNFα) for coexisting conditions may experience unexpected exacerbations of TB after the initiation of antituberculous therapy, so-called anti-TNFα-induced TB-immune reconstitution inflammatory syndrome (anti-TNFα-induced TB-IRIS). Anti-TNFα-induced TB-IRIS is often treated empirically with corticosteroids; however, the evidence of the effectiveness of corticosteroids is lacking and the management can be a challenge. PATIENT CONCERNS A 32-year-old man on long-term infliximab therapy for Crohn disease visited a clinic complaining of persistent fever and cough that had started 1 week previously. His most recent infliximab injection had been administered 14 days before the visit. A chest X-ray revealed a left pleural effusion, and he was admitted to a local hospital. DIAGNOSIS A chest computed tomography (CT) scan revealed miliary pulmonary nodules; acid-fast bacilli were found in a sputum smear and a urine sediment sample; and polymerase chain reaction confirmed the presence of Mycobacterium tuberculosis in both his sputum and the pleural effusion. He was diagnosed with miliary TB. INTERVENTIONS Antituberculous therapy was started and he was transferred to our hospital for further management. His symptoms initially improved after the initiation of antituberculous therapy, but 2 weeks later, his symptoms recurred and shadows on chest X-ray worsened. A repeat chest CT scan revealed enlarged miliary pulmonary nodules, extensive ground-glass opacities, and an increased volume of his pleural effusion. This paradoxical exacerbation was diagnosed as TB-IRIS associated with infliximab. A moderate-dose of systemic corticosteroid was initiated [prednisolone 25 mg/day (0.5 mg/kg/day)]. OUTCOMES After starting corticosteroid treatment, his radiological findings improved immediately, and his fever and cough disappeared within a few days. After discharge, prednisolone was tapered off over the course of 10 weeks, and he completed a 9-month course of antituberculous therapy uneventfully. He had not restarted infliximab at his most recent follow-up 14 months later. CONCLUSION We successfully managed a patient with anti-TNFα-induced TB-IRIS using moderate-dose corticosteroids. Due to the limited evidence currently available, physicians should consider the necessity, dosage, and duration of corticosteroids for each case of anti-TNFα-induced TB-IRIS on an individual patient-by-patient basis.
Collapse
Affiliation(s)
- Daijiro Nabeya
- Department of Infectious, Respiratory, and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus
- Department of Respiratory Medicine, Okinawa Chubu Hospital
| | - Takeshi Kinjo
- Department of Infectious, Respiratory, and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus
| | - Kazutaka Yamaniha
- Department of Infectious, Respiratory, and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus
| | - Shoshin Yamazato
- Department of Infectious, Respiratory, and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus
| | - Reo Tome
- Department of Infectious, Respiratory, and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus
| | - Kazuya Miyagi
- Department of Infectious, Respiratory, and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus
| | - Hideta Nakamura
- Department of Infectious, Respiratory, and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus
| | - Tetsu Kinjo
- Department of Infectious, Respiratory, and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus
| | - Shusaku Haranaga
- Department of Infectious, Respiratory, and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus
| | - Futoshi Higa
- Department of Respiratory Medicine, National Hospital Organization Okinawa National Hospital, Okinawa, Japan
| | - Jiro Fujita
- Department of Infectious, Respiratory, and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus
| |
Collapse
|
39
|
Ganatra SR, Bucşan AN, Alvarez X, Kumar S, Chatterjee A, Quezada M, Fish A, Singh DK, Singh B, Sharan R, Lee TH, Shanmugasundaram U, Velu V, Khader SA, Mehra S, Rengarajan J, Kaushal D. Antiretroviral therapy does not reduce tuberculosis reactivation in a tuberculosis-HIV coinfection model. J Clin Invest 2020; 130:5171-5179. [PMID: 32544085 PMCID: PMC7524506 DOI: 10.1172/jci136502] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 06/04/2020] [Indexed: 12/12/2022] Open
Abstract
While the advent of combination antiretroviral therapy (ART) has significantly improved survival, tuberculosis (TB) remains the leading cause of death in the HIV-infected population. We used Mycobacterium tuberculosis/simian immunodeficiency virus-coinfected (M. tuberculosis/SIV-coinfected) macaques to model M. tuberculosis/HIV coinfection and study the impact of ART on TB reactivation due to HIV infection. Although ART significantly reduced viral loads and increased CD4+ T cell counts in blood and bronchoalveolar lavage (BAL) samples, it did not reduce the relative risk of SIV-induced TB reactivation in ART-treated macaques in the early phase of treatment. CD4+ T cells were poorly restored specifically in the lung interstitium, despite their significant restoration in the alveolar compartment of the lung as well as in the periphery. IDO1 induction in myeloid cells in the inducible bronchus-associated lymphoid tissue (iBALT) likely contributed to dysregulated T cell homing and impaired lung immunity. Thus, although ART was indispensable for controlling viral replication, restoring CD4+ T cells, and preventing opportunistic infection, it appeared inadequate in reversing the clinical signs of TB reactivation during the relatively short duration of ART administered in this study. This finding warrants the modeling of concurrent treatment of TB and HIV to potentially reduce the risk of reactivation of TB due to HIV to inform treatment strategies in patients with M. tuberculosis/HIV coinfection.
Collapse
Affiliation(s)
- Shashank R. Ganatra
- Southwest National Primate Research Center (SNPRC), Texas Biomedical Research Institute, San Antonio, Texas, USA
| | - Allison N. Bucşan
- Tulane National Primate Research Center (TNPRC), Covington, Louisiana, USA
| | - Xavier Alvarez
- Southwest National Primate Research Center (SNPRC), Texas Biomedical Research Institute, San Antonio, Texas, USA
- Tulane National Primate Research Center (TNPRC), Covington, Louisiana, USA
| | - Shyamesh Kumar
- Southwest National Primate Research Center (SNPRC), Texas Biomedical Research Institute, San Antonio, Texas, USA
| | - Ayan Chatterjee
- Southwest National Primate Research Center (SNPRC), Texas Biomedical Research Institute, San Antonio, Texas, USA
| | - Melanie Quezada
- Emory Vaccine Center and
- Yerkes National Primate Research Center (YNPRC), Emory University School of Medicine, Atlanta, Georgia, USA
| | - Abigail Fish
- Southwest National Primate Research Center (SNPRC), Texas Biomedical Research Institute, San Antonio, Texas, USA
| | - Dhiraj K. Singh
- Southwest National Primate Research Center (SNPRC), Texas Biomedical Research Institute, San Antonio, Texas, USA
| | - Bindu Singh
- Southwest National Primate Research Center (SNPRC), Texas Biomedical Research Institute, San Antonio, Texas, USA
| | - Riti Sharan
- Southwest National Primate Research Center (SNPRC), Texas Biomedical Research Institute, San Antonio, Texas, USA
| | - Tae-Hyung Lee
- Southwest National Primate Research Center (SNPRC), Texas Biomedical Research Institute, San Antonio, Texas, USA
| | - Uma Shanmugasundaram
- Emory Vaccine Center and
- Yerkes National Primate Research Center (YNPRC), Emory University School of Medicine, Atlanta, Georgia, USA
| | - Vijayakumar Velu
- Emory Vaccine Center and
- Yerkes National Primate Research Center (YNPRC), Emory University School of Medicine, Atlanta, Georgia, USA
| | - Shabaana A. Khader
- Department of Molecular Microbiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Smriti Mehra
- Tulane National Primate Research Center (TNPRC), Covington, Louisiana, USA
| | - Jyothi Rengarajan
- Emory Vaccine Center and
- Yerkes National Primate Research Center (YNPRC), Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Deepak Kaushal
- Southwest National Primate Research Center (SNPRC), Texas Biomedical Research Institute, San Antonio, Texas, USA
| |
Collapse
|
40
|
Gaillet A, Calin R, Flandre P, Tubiana R, Valantin MA, Caumes E, Katlama C, Pourcher V. Increased risk of IRIS-associated tuberculosis in HIV-infected patients receiving Integrase Inhibitors. Infect Dis Now 2020; 51:90-93. [PMID: 33007401 DOI: 10.1016/j.medmal.2020.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 09/21/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Tuberculosis is associated with a risk of immune reconstitution inflammatory syndrome (IRIS) after ART initiation. METHODS Data from all patients with newly diagnosed tuberculosis disease and uncontrolled HIV infection from 1997 to 2017 in a French center were retrospectively collected. We evaluated the incidence of tuberculosis-IRIS in patients initiating ART with or without integrase inhibitors (INSTI) RESULTS: Fifty-five patients were included: 21 receiving an INSTI regimen and 34 a non-INSTI regimen. Except with regard to ART regimen, the two groups were comparable (median CD4 of 85/mm3). The overall percentage of IRIS was 34% (19/55), with 52% IRIS in INSTI regimen and 23% in non-INSTI regimen respectively (P=0.04). In a multivariate logistic model, we observed an increased risk of IRIS in the INSTI regimen compared to the non-INSTI, with an OR at 3.33 [95% CI, 1.01-11.1] (P=0.05) CONCLUSIONS: ART containing integrase inhibitors could be associated with increased incidence of TB-associated IRIS.
Collapse
Affiliation(s)
- A Gaillet
- Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Department of Infectious Diseases, Pitie-Salpetriere Hospital, 47-83 Boulevard de l'Hôpital, Paris 75013, France.
| | - R Calin
- Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Department of Infectious Diseases, Pitie-Salpetriere Hospital, 47-83 Boulevard de l'Hôpital, Paris 75013, France; Inserm UMR-S 1136, Pierre Louis Institute of Epidemiology and Public Health, Sorbonne Université, Paris, France
| | - P Flandre
- Inserm UMR-S 1136, Pierre Louis Institute of Epidemiology and Public Health, Sorbonne Université, Paris, France
| | - R Tubiana
- Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Department of Infectious Diseases, Pitie-Salpetriere Hospital, 47-83 Boulevard de l'Hôpital, Paris 75013, France; Inserm UMR-S 1136, Pierre Louis Institute of Epidemiology and Public Health, Sorbonne Université, Paris, France
| | - M-A Valantin
- Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Department of Infectious Diseases, Pitie-Salpetriere Hospital, 47-83 Boulevard de l'Hôpital, Paris 75013, France; Inserm UMR-S 1136, Pierre Louis Institute of Epidemiology and Public Health, Sorbonne Université, Paris, France
| | - E Caumes
- Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Department of Infectious Diseases, Pitie-Salpetriere Hospital, 47-83 Boulevard de l'Hôpital, Paris 75013, France; Inserm UMR-S 1136, Pierre Louis Institute of Epidemiology and Public Health, Sorbonne Université, Paris, France
| | - C Katlama
- Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Department of Infectious Diseases, Pitie-Salpetriere Hospital, 47-83 Boulevard de l'Hôpital, Paris 75013, France; Inserm UMR-S 1136, Pierre Louis Institute of Epidemiology and Public Health, Sorbonne Université, Paris, France
| | - V Pourcher
- Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Department of Infectious Diseases, Pitie-Salpetriere Hospital, 47-83 Boulevard de l'Hôpital, Paris 75013, France; Inserm UMR-S 1136, Pierre Louis Institute of Epidemiology and Public Health, Sorbonne Université, Paris, France
| |
Collapse
|
41
|
Zimba S, Mbewe N, Chishimba L, Chomba M, Saylor D. Immune reconstitution inflammatory syndrome: a report of TB-IRIS after switching from efavirenz to dolutegravir. Trop Doct 2020; 51:216-218. [PMID: 32903146 DOI: 10.1177/0049475520953704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In 2016, the World Health Organization adopted dolutegravir (DTG)-based antiretroviral therapy as an alternative first-line treatment of HIV after many clinical trials showed that it was more effective, better tolerated and more protective than efavirenz and boosted protease inhibitors against discontinuation of treatment from adverse drug reactions. However, there was concern that DTG would lead to increased rates of immune reconstitution inflammatory syndrome (IRIS), especially in the setting of late presentation to care. Three cases at the University Teaching Hospital in Lusaka, Zambia highlight this concern, especially in persons living with HIV (PLWH), resulting in tuberculosis (TB) co-infection.
Collapse
Affiliation(s)
- Stanley Zimba
- Internal Medicine Consultant and Neurology Registrar, Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia
| | - Nyuma Mbewe
- Infectious Diseases Registrar, Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia
| | - Lorraine Chishimba
- Neurology Registrar, Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia
| | - Mashina Chomba
- Neurology Registrar, Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia
| | - Deanna Saylor
- Honorary Consultant, University Teaching Hospital, Lusaka, Zambia.,Assistant Professor of Neurology, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
42
|
Xue M, Xie R, Pang Y, Yan S, Du Y, Guan C, Chen B. Prevalence and risk factors of paradoxical tuberculosis associated immune reconstitution inflammatory syndrome among HIV-infected patients in Beijing, China. BMC Infect Dis 2020; 20:554. [PMID: 32736608 PMCID: PMC7393886 DOI: 10.1186/s12879-020-05225-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 07/03/2020] [Indexed: 01/01/2023] Open
Abstract
Background In this study, we aimed to describe the prevalence, clinical presentation and risk factors of paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) cases in China. Methods We performed a descriptive analysis of demographic and clinical data of HIV/TB coinfected patients receiving ART at Beijing Ditan Hospital between January 2014 and October 2018. Results Of 199 patients included, 45 (22.6%) developed paradoxical TB-IRIS, and 19 (9.5%) TB-IRIS cases presented miliary TB. The pre-ART CD4 count lower than 50 cells/mm3 was found to be significantly associated with development of TB-IRIS. Similarly, patients with higher than 4-fold increase in CD4 cell count after antiretroviral therapy (ART) had significantly higher odds of having TB-IRIS. When patients aged 25–44 years were utilized as the control group, youths (< 25 years old) were more likely to have miliary TB. No significant difference was observed in the intervals from initiation of ART to IRIS presentation between miliary and non-miliary group. Conclusions In conclusion, our data demonstrate that approximate one quarter of patients coinfected with TB and HIV develop paradoxical TB-IRIS after initial of ART therapy in China. Lower baseline CD4 count and rapid increase in CD4 count are the major risk factors associated with the occurrence of paradoxical TB-IRIS.
Collapse
Affiliation(s)
- Ming Xue
- Department of Radiology, Beijing Ditan Hospital, Capital Medical University, No. 8, Jingshun East Street, Chaoyang District, Beijing, 100015, P. R. China
| | - Ruming Xie
- Department of Radiology, Beijing Ditan Hospital, Capital Medical University, No. 8, Jingshun East Street, Chaoyang District, Beijing, 100015, P. R. China
| | - Yu Pang
- National Clinical Laboratory on Tuberculosis, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis & Thoracic Tumor Research Institute, Beijing, 101149, P. R. China
| | - Shuo Yan
- Department of Radiology, Beijing Ditan Hospital, Capital Medical University, No. 8, Jingshun East Street, Chaoyang District, Beijing, 100015, P. R. China
| | - Yanni Du
- Department of Radiology, Beijing Ditan Hospital, Capital Medical University, No. 8, Jingshun East Street, Chaoyang District, Beijing, 100015, P. R. China
| | - Chunshuang Guan
- Department of Radiology, Beijing Ditan Hospital, Capital Medical University, No. 8, Jingshun East Street, Chaoyang District, Beijing, 100015, P. R. China
| | - Budong Chen
- Department of Radiology, Beijing Ditan Hospital, Capital Medical University, No. 8, Jingshun East Street, Chaoyang District, Beijing, 100015, P. R. China.
| |
Collapse
|
43
|
Narendran G, Jyotheeswaran K, Senguttuvan T, Vinhaes CL, Santhanakrishnan RK, Manoharan T, Selvaraj A, Chandrasekaran P, Menon PA, Bhavani KP, Reddy D, Narayanan R, Subramanyam B, Sathyavelu S, Krishnaraja R, Kalirajan P, Angamuthu D, Susaimuthu SM, Ganesan RRK, Tripathy SP, Swaminathan S, Andrade BB. Characteristics of paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome and its influence on tuberculosis treatment outcomes in persons living with HIV. Int J Infect Dis 2020; 98:261-267. [PMID: 32623087 DOI: 10.1016/j.ijid.2020.06.097] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/27/2020] [Accepted: 06/29/2020] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE The influence of tuberculosis (TB)-immune reconstitution inflammatory syndrome (IRIS) on TB treatment outcomes and its risk factors were investigated among people with human immunodeficiency virus (HIV) and co-infected with TB. METHODS Newly diagnosed, culture-confirmed, pulmonary TB patients with HIV and enrolled in a clinical trial (NCT00933790) were retrospectively analysed for IRIS occurrence. Risk factors and TB outcomes (up to 18 months after initiation of anti-TB treatment [ATT]) were compared between people who experienced IRIS (IRIS group) and those who did not (non-IRIS group). RESULTS TB-IRIS occurred in 82 of 292 (28%) participants. Significant baseline risk factors predisposing to TB-IRIS occurrence in univariate analysis were: lower CD4+ T-cell count, CD4/CD8 ratio, haemoglobin levels, presence of extra-pulmonary TB focus, and higher HIV viral load; the last two retained significance in the multivariate analysis. After 2 months of ATT commencement, sputum smear conversion was documented in 45 of 80 (56.2%) vs. 124 of 194 (63.9%) (p=0.23), culture conversion was in 75 of 80 (93.7%) vs. 178 of 194 (91.7%) (p=0.57) and the median decline in viral load (log10copies/mm3) was 2.7 in the IRIS vs. 1.1 in the non-IRIS groups (p<0.0001), respectively. An unfavourable response to TB therapy was detected in 17 of 82 (20.7%) and 28 of 210 (13.3%) in the IRIS and non-IRIS groups, respectively (p=0.14). CONCLUSIONS TB-IRIS frequently occurred in people with advanced HIV infection and in those who presented with extra-pulmonary TB lesions, without influencing subsequent TB treatment outcomes.
Collapse
Affiliation(s)
- Gopalan Narendran
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Keerthana Jyotheeswaran
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Thirumaran Senguttuvan
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Caian L Vinhaes
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil; Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil; Curso de Medicina, Faculdade de Tecnologia e Ciências (UniFTC), Salvador, Brazil
| | - Ramesh K Santhanakrishnan
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Tamizhselvan Manoharan
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Anbhalagan Selvaraj
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | | | - Pradeep A Menon
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Kannabiran P Bhavani
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Devarajulu Reddy
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Ravichandran Narayanan
- Government Hospital of Thoracic Medicine, Tambaram Sanatorium, Chennai, Tamil Nadu, India
| | - Balaji Subramanyam
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Sekhar Sathyavelu
- Rajiv Gandhi Government General Hospital, Park Town, Chennai, Tamil Nadu, India
| | - Raja Krishnaraja
- Government Hospital of Thoracic Medicine, Tambaram Sanatorium, Chennai, Tamil Nadu, India
| | - Pownraj Kalirajan
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Dhanalakshmi Angamuthu
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Stella Mary Susaimuthu
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | | | - Srikanth P Tripathy
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | | | - Bruno B Andrade
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil; Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil; Curso de Medicina, Faculdade de Tecnologia e Ciências (UniFTC), Salvador, Brazil; Universidade Salvador (UNIFACS), Laureate Universities, Salvador, Brazil; Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, Brazil; Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
| |
Collapse
|
44
|
Suryana K. <p>A Challenge in Diagnosis of Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome (TB-IRIS)</p>. HIV AIDS (Auckl) 2020; 12:263-269. [PMID: 32801925 PMCID: PMC7398877 DOI: 10.2147/hiv.s254105] [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: 03/30/2020] [Accepted: 06/27/2020] [Indexed: 12/05/2022] Open
Abstract
Tuberculosis immune reconstitution inflammatory syndrome (TB-IRIS) in HIV-infected patients is the sign and symptom of exacerbation, or radiological manifestation of Mycobacterium tuberculosis (Mtb) infection, can describe the improvement of the immune system after initiating highly active antiretroviral therapy (HAART). No approved or explicit symptomatic tests for TB-IRIS exist, the diagnosis depends on the clinical manifestations. Here we report a TB-IRIS case with diagnostic challenges.
Collapse
Affiliation(s)
- Ketut Suryana
- Department of Internal Medicine, Merpati Clinic, HIV and Allergy - Clinical Immunology Services Unit, Wangaya Hospital, Denpasar, Bali, Indonesia
- Correspondence: Ketut Suryana Department of Internal Medicine; Merpati Clinic; HIV and Allergy - Clinical Immunology Services Unit, Wangaya Hospital, Akasia Street, VIII No. 22, Denpasar, Bali80235, IndonesiaTel +628 5953783944 Email
| |
Collapse
|
45
|
Meintjes G, Brust JCM, Nuttall J, Maartens G. Management of active tuberculosis in adults with HIV. Lancet HIV 2020; 6:e463-e474. [PMID: 31272663 DOI: 10.1016/s2352-3018(19)30154-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 04/25/2019] [Accepted: 05/08/2019] [Indexed: 12/11/2022]
Abstract
Every year, about 1 million people living with HIV worldwide develop tuberculosis. Although the drug regimens used to treat tuberculosis in these patients are the same as those used in HIV-negative patients, cotreatment of tuberculosis with antiretroviral therapy involves challenges including the optimal timing of antiretroviral initiation, drug-drug interactions, drug tolerability, and the prevention and treatment of tuberculosis-associated immune reconstitution syndrome. Furthermore, mortality is high in people with HIV who are diagnosed with tuberculosis during a hospital admission, and in those with tuberculous meningitis. Studies in this field have better characterised these challenges and informed optimal management and guideline revisions. In patients with tuberculosis, antiretroviral therapy improves survival, is well tolerated, and can be adjusted to manage drug-drug interactions with rifampicin. Prednisone is effective in both preventing and treating the paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome.
Collapse
Affiliation(s)
- Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, South Africa; Division of Infectious Diseases and HIV Medicine, Department of Medicine, South Africa.
| | - James C M Brust
- University of Cape Town, Observatory, South Africa; Divisions of General Internal Medicine and Infectious Diseases, Albert Einstein College of Medicine, New York, NY, USA
| | - James Nuttall
- Department of Paediatrics and Child Health, South Africa
| | - Gary Maartens
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, South Africa; Division of Clinical Pharmacology, Department of Medicine, South Africa
| |
Collapse
|
46
|
Effect of Xpert MTB/RIF testing introduction and favorable outcome predictors for tuberculosis treatment among HIV infected adults in rural southern Mozambique. A retrospective cohort study. PLoS One 2020; 15:e0229995. [PMID: 32150595 PMCID: PMC7062249 DOI: 10.1371/journal.pone.0229995] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 02/19/2020] [Indexed: 01/22/2023] Open
Abstract
Background Global roll out of Xpert MTB/RIF technology has resulted in dramatic changes in TB diagnosis. However, benefits in resource-limited, high-burden TB/HIV settings, remain to be verified. In this paper we describe the characteristics of a large cohort of TB patients in a rural hospital in Southern Mozambique before and after Xpert MTB/RIF introduction, together with some determinants of favorable treatment outcome. Methods We conducted a retrospective cohort study of TB infected patients ≥15 years of age, diagnosed and treated at Carmelo Hospital of Chókwè between January 1, 2006 and December 31, 2017. Patient demographic and clinical characteristics, and treatment outcomes were recorded and compared before and after Xpert MTB/RIF, which was introduced in the second semester of 2012. Results 9,655 patients were analyzed, with 44.1% females. HIV testing was conducted in 99.9% of patients, with 82.8% having TB/HIV co-infection. 73.2% of patients had a favorable treatment outcome. No increase was observed in the number of TB patients identified after introduction of Xpert MTB/RIF testing. Conclusion Upon introduction, Xpert testing seemed to have a punctual beneficial effect on TB treatment outcomes, however this effect apparently disappeared shortly afterwards. Challenges remain for integration of TB and HIV care, as worse outcomes are reported for those patients diagnosed with TB shortly after starting ART, and also for those never starting ART. The need of reasonably excluding TB disease before ART start should be highlighted to every health care provider engaged in HIV care.
Collapse
|
47
|
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
|
48
|
Cerrone M, Bracchi M, Wasserman S, Pozniak A, Meintjes G, Cohen K, Wilkinson RJ. Safety implications of combined antiretroviral and anti-tuberculosis drugs. Expert Opin Drug Saf 2020; 19:23-41. [PMID: 31809218 PMCID: PMC6938542 DOI: 10.1080/14740338.2020.1694901] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 11/15/2019] [Indexed: 01/01/2023]
Abstract
Introduction: Antiretroviral and anti-tuberculosis (TB) drugs are often co-administered in people living with HIV (PLWH). Early initiation of antiretroviral therapy (ART) during TB treatment improves survival in patients with advanced HIV disease. However, safety concerns related to clinically significant changes in drug exposure resulting from drug-drug interactions, development of overlapping toxicities and specific challenges related to co-administration during pregnancy represent barriers to successful combined treatment for HIV and TB.Areas covered: Pharmacokinetic interactions of different classes of ART when combined with anti-TB drugs used for sensitive-, drug-resistant (DR) and latent TB are discussed. Overlapping drug toxicities, implications of immune reconstitution inflammatory syndrome (IRIS), safety in pregnancy and research gaps are also explored.Expert opinion: New antiretroviral and anti-tuberculosis drugs have been recently introduced and international guidelines updated. A number of effective molecules and clinical data are now available to build treatment regimens for PLWH with latent or active TB. Adopting a systematic approach that also takes into account the need for individualized variations based on the available evidence is the key to successfully integrate ART and TB treatment and improve treatment outcomes.
Collapse
Affiliation(s)
- Maddalena Cerrone
- Department of Medicine, Imperial College London, W2 1PG, UK
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory 7925, South Africa
- Department of HIV, Chelsea and Westminster Hospital NHS Trust, London, UK
- Francis Crick Institute, London, NW1 1AT, UK
| | - Margherita Bracchi
- Department of HIV, Chelsea and Westminster Hospital NHS Trust, London, UK
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory 7925, South Africa
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Anton Pozniak
- Department of HIV, Chelsea and Westminster Hospital NHS Trust, London, UK
- The London School of Hygiene & Tropical Medicine
| | - 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, Observatory 7925, South Africa
| | - Karen Cohen
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - Robert J Wilkinson
- Department of Medicine, Imperial College London, W2 1PG, UK
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory 7925, South Africa
- Francis Crick Institute, London, NW1 1AT, UK
| |
Collapse
|
49
|
Leal VNC, Reis EC, Pontillo A. Inflammasome in HIV infection: Lights and shadows. Mol Immunol 2019; 118:9-18. [PMID: 31835091 DOI: 10.1016/j.molimm.2019.12.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 11/27/2019] [Accepted: 12/03/2019] [Indexed: 02/07/2023]
Abstract
The importance of inflammasome, and related cytokines IL-1ß and IL-18, in host defense against pathogens is well documented, however, at the same time, dysregulation of inflammasome has been associated to multifactorial diseases characterized by chronic inflammation (i.e.: metabolic disorders, cardiovascular diseases, neurodegenerative diseases, autoimmunity, cancer). Inflammasome activation has been described in response to HIV-1 and possibly contributes to the resistance against virus establishment, however, on the other hand, when viral infection becomes chronic, independently from antiretroviral therapy, the increase constitutive activation of inflammasome has been eventually associated to a worse prognosis, raising the question about the role played by inflammasome and/or some specific receptors in this context. Due to the chance to imply targeted therapies that inhibit inflammasome activation and/or cytokines release, it will be important to define the impact of the complex in the pathogenesis of HIV. The purpose of this review is to depict the double-faced inflammasome role in HIV-1 infection, trying to unveil whether besides its role in first line defense against the virus, it exerts a harmful effect during the chronic phase of infection.
Collapse
Affiliation(s)
- Vinicius Nunes Cordeiro Leal
- Laboratorio de Imunogenetica, Departamento de Imunologia, Instituto de Ciencias Biomedicas (ICB), Universidade de Sao Paulo (USP), Sao Paulo, SP, Brazil
| | - Edione Cristina Reis
- Laboratorio de Imunogenetica, Departamento de Imunologia, Instituto de Ciencias Biomedicas (ICB), Universidade de Sao Paulo (USP), Sao Paulo, SP, Brazil
| | - Alessandra Pontillo
- Laboratorio de Imunogenetica, Departamento de Imunologia, Instituto de Ciencias Biomedicas (ICB), Universidade de Sao Paulo (USP), Sao Paulo, SP, Brazil.
| |
Collapse
|
50
|
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
|