The roles of microRNAs on tuberculosis infection: meaning or myth?

The central proteins for protection against tuberculosis are attributed to interferon-γ, tumor necrosis factor-α, interleukin (IL)-6 and IL-1β, while IL-10 primarily suppresses anti-mycobacterial responses. Several studies found alteration of expression profile of genes involved in anti-mycobacterial responses in macrophages and natural killer (NK) cells from active and latent tuberculosis and from tuberculosis and healthy controls. This alteration of cellular composition might be regulated by microRNAs (miRNAs). Albeit only 1% of the genomic transcripts in mammalian cells encode miRNA, they are predicted to control the activity of more than 60% of all protein-coding genes and they have a huge influence in pathogenesis theory, diagnosis and treatment approach to some diseases. Several miRNAs have been found to regulate T cell differentiation and function and have critical role in regulating the innate function of macrophages, dendritic cells and NK cells. Here, we have reviewed the role of miRNAs implicated in tuberculosis infection, especially related to their new roles in the molecular pathology of tuberculosis immunology and as new targets for future tuberculosis diagnostics.

Host genome polymorphisms and tuberculosis infection: What we have to say?

Several epidemiology studies suggest that host genetic factors play important roles in susceptibility, protection and progression of tuberculosis infection. Here we have reviewed the implications of some genetic polymorphisms in pathways related to tuberculosis susceptibility, severity and development. Large case-control studies examining single-nucleotide polymorphisms (SNPs) in genes have been performed in tuberculosis patients in some countries. Polymorphisms in natural resistance-associated macrophage protein 1 (NRAMP1), toll-like receptor 2 (TLR2), interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-α), interleukin-1 receptor antagonist (IL-1RA), IL-10, vitamin D receptor (VDR), dendritic cell-specific ICAM-3-grabbing non-integrin (DC-SIGN), monocyte chemoattractant protein-1 (MCP-1), nucleotide oligomerization binding domain 2 (NOD2), interferon-gamma (IFN-γ), inducible nitric oxide synthase (iNOS), mannose-binding lectin (MBL) and surfactant proteins A (SP-A) have been reviewed. These genes have been variably associated with tuberculosis infection and there is strong evidence indicating that host genetic factors play critical roles in tuberculosis susceptibility, severity and development.

Long non-coding RNA molecules in tuberculosis

Tuberculosis (TB), a chronic disease caused by Mycobacterium tuberculosis, is one of the deadliest infectious diseases in the world. Despite significant advances in detection techniques and therapeutic approaches for tuberculosis, there is still no suitable solution for early screening and reducing the number of individuals affected and their effective treatment. Various cellular events can disrupt the development of TB. The basis of these events is dysregulating of genes expression patterns related with specific molecules. Long non-coding RNAs (lncRNAs) are molecules discovered to regulate the expression of protein-coding genes and participate in gene silencing, cell cycle regulation and cellular differentiation processes. Dysregulation of lncRNAs has been found to be associated with many diseases, including cancers and infectious diseases. Thus, the recognition of lncRNAs as novel molecular biomarkers and therapeutic targets for tuberculosis is promising. In the present review, we try to summarize the current findings of lncRNA expression patterns and its role in tuberculosis infection process.

Use of IFN-γ and IP-10 detection in the diagnosis of latent tuberculosis infection in patients with inflammatory rheumatic diseases

OBJECTIVES

Biologic agents are used against rheumatic diseases, however, they increase the risk of developing severe infections and diseases such as tuberculosis. We aimed to determine the benefits of IP-10 detection to diagnose latent tuberculosis infection (LTBI) in patients with inflammatory rheumatic diseases on different immunosuppressive drug regimens, and compare these results with IFN-γ detection.

MATERIALS AND METHODS

We included 64 patients with inflammatory rheumatic diseases. We used QuantiFERON Gold In-Tube (QFN-G-IT) and T-SPOT.TB to detect IFN-γ production, and an in-house ELISA for IP-10 detection from the previous QFN-G-IT stimulated samples. We assessed the combined use of IFN-γ release assays (IGRAs) and IP-10 test, and analyzed the influence of immunotherapy on the tests performance.

RESULTS

We obtained 34.9% positive results by T-SPOT.TB, 25.0% by QFN-G-IT and 31.3% by IP-10 test. The combined use of IGRAs and IP-10 detection increased significantly the amount of positive results (p < 0.0001). Treatment intake had no significant effect on in vitro tests (p > 0.05).

CONCLUSIONS

IP-10 and IFN-γ detection is comparable and their combined use could increase the number of positive results in the diagnosis of LTBI in rheumatic patients. The tested assays were not influenced by rheumatoid immunosuppressive therapy. Thus, IP-10 could be of use in the development of new and improved LTBI diagnostic tools.

The potential of CBC-derived ratios (monocyte-to-lymphocyte, neutrophil-to-lymphocyte, and platelet-to-lymphocyte) to predict or diagnose incident TB infection in Tanzanian adolescents

Background

Ratios of different immune cell populations (i.e., monocyte-to-lymphocyte, neutrophil-to-lymphocyte, and platelet-to-lymphocyte ratios) have been studied as a means of predicting future tuberculosis (TB) disease risk or to assist in the diagnosis of incident TB disease. No studies to-date, however, have evaluated the potential of these ratios to predict or assist in the diagnosis of incident TB infection - the first step in the natural history of TB disease.

Methods

In this prospective study, we evaluated the complete blood count (CBC)-derived metrics of monocyte-to-lymphocyte ratio (MLR), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) as predictors of future TB infection risk or aids in the diagnosis of TB infection among 145 Tanzanian adolescents enrolled in the DAR-901 vaccine trial, using paired CBCs and interferon-gamma release assays (IGRAs) obtained at 0, 60 and 720 days after study enrollment.

Results

At baseline, there were no significant differences between study participants who remained persistently IGRA negative throughout the study period and those who subsequently converted to IGRA positive with respect to MLR (0.18 vs 0.17, p = 0.10), NLR (0.88 vs 1.02, p = 0.08), or PLR (115 vs 120, p = 0.28). Similarly, no significant differences were noted with respect to MLR, NLR, and PLR between IGRA converters and time-matched negative controls at the time of IGRA conversion. With respect to other blood cell measures, however, there were modest but significant differences between IGRA negatives and IGRA converters with respect to red blood cell count (4.8 vs 4.6 ×  10⁶ cells/mcL, p = 0.008), hemoglobin (12.6 vs 12.3 g/dL, p = 0.01), and hematocrit (38.8 vs 37.8%, p = 0.005).

Conclusions

In contrast to prior studies that have suggested that the ratios of different immune cell populations are associated with development of TB disease, our present findings do not demonstrate an association between these ratios and the development of TB infection. However, decreased red blood cell measures were associated with the subsequent development of TB infection, suggesting either that dysregulation of iron metabolism may play a role in TB pathogenesis or that following TB infection, iron dysregulation may precede IGRA positivity.

Trial registration

Clinicaltrials.gov NCT02712424. Date of registration: March 14, 2016.

Programmatic management of Tuberculosis preventive therapy: past, present, future

BACKGROUND

Tuberculosis infection (TBI) is an emerging public health priority, involving about one fourth of the world population. Since persons with TBI are the reservoir for tuberculosis (TB), stopping progression to active disease by preventive treatment is one of the main interventions needed to achieve TB elimination. As of today, the proportion of people with TBI receiving treatment is minimal, at global level, mostly because current international policies recommend systematic testing and treatment for less than 2% of infected people. PRESENT: : facts and gaps: The programmatic management of TB preventive treatment (PMTPT) involves a set of cascading interventions whose effectiveness is limited by the poor predictivity of diagnostic tests, the length and the potential toxicity of treatment, and the suboptimal prioritisation within global policies. Partly because of this, competing priorities and lack of adequate funding are significant barriers for scale up, particularly in low- and middle-income countries.

MONITORING AND EVALUATION

To date there is no universal system of monitoring and evaluation for the PMTPT elements and just a few countries use standard recording and reporting tools, contributing to leaving TBI a neglected condition.

CONCLUSIONS

Better financed research and resources reallocation are essential steps to progress towards TB elimination worldwide.

Adults with Mycobacterium tuberculosis infection and pre-diabetes have increased levels of QuantiFERON interferon-gamma responses

BACKGROUND

Diabetes is associated with increased prevalence of TB infection in the US. We assessed associations between diabetes and interferon-gamma (IFN-γ) TB antigen response among adults with TB infection using US representative data.

METHODS

National Health and Nutrition Examination (NHANES) participants >19 years from 2011 to 2012 with positive QuantiFERON®-TB Gold-In-Tube (QFT) results were eligible. Diabetes was defined by combination of self-report and glycated hemoglobin (HbA1c). Quantitative IFN-γ TB antigen was classified as high (≥10 IU/mL), intermediate (1.01-9.99 IU/mL), or low (0.35-1.00 IU/mL). Analyses accounted for NHANES weighted design.

RESULTS

Among NHANES participants >19 years, n = 513 had positive QFT (5.9%). Among those with positive QFT, diabetes prevalence was 22.2% and pre-diabetes was 25.9%. Overall, 16.7% of positive QFT participants had high IFN-γ TB antigen levels including 21.7% among those with diabetes, 20.8% among those with pre-diabetes, and 12.6% among euglycemic participants. In adjusted analyses, high IFN-γ TB antigen response was more common among those with pre-diabetes (aOR 1.9, 95%CI 1.0, 3.6) compared to euglycemic participants.

CONCLUSION

Higher antigen responses may reflect immunopathy consistent with an exaggerated inflammatory but ineffectual response to TB or a reflection of more Mtb replication in participants with pre-diabetes or diabetes.

Detection of Mycobacterium tuberculosis DNA in CD34+ peripheral blood mononuclear cells of adults with tuberculosis infection and disease

OBJECTIVES

To investigate whether Mycobacterium tuberculosis (Mtb) DNA is detected in peripheral blood mononuclear cells (PBMC) of subjects with tuberculosis (TB) or TB infection (TBI) living in a low-burden country.

METHODS

We prospectively enrolled 57 patients with TB, 41 subjects with TBI, and 39 controls in Rome, Italy. PBMC were isolated, cluster of differentiation (CD)34+ and CD34- cells were immunomagnetic separated, DNA was extracted, and digital polymerase chain reaction for IS6110 and rpoB sequences was used to detect Mtb DNA in PBMC subsets and unfractionated PBMC.

RESULTS

We detected Mtb DNA at a low copy number in CD34+ cells in 4o f 30 (13%) patients with TB, 2 of 24 (8%) subjects with TBI, and 1 of 24 (4%) controls. Mtb DNA was detected in unfractionated PBMC in 3 of 51 (6%) patients with TB, 2 of 38 (5%) subjects with TBI, and 2 of 36 (6%) controls. In CD34- cells, only 1 of 31 (3%) subjects with TBI tested positive for Mtb DNA.

CONCLUSIONS

Mtb DNA was detected at low frequencies and levels in the PBMC of subjects with TBI and donors with TB living in a low-burden country. In particular, Mtb DNA was detected more frequently in CD34+ cells, supporting the hypothesis that these cells may represent a Mtb niche. This finding informs biological understanding of Mtb pathogenesis and may support the development of a microbial blood biomarker for Mtb infection.

[Description of tuberculosis outbreak and usefulness of mediastinal ultrasound]

OBJECTIVES

Describe a school outbreak of tuberculosis and compare the features with other outbreaks. Propose mediastinal ultrasound as an aid in its diagnosis and monitoring.

PATIENTS AND METHODS

Retrospective descriptive study of the transmission of tuberculosis infection in a micro-epidemic. Infection criteria: Mantoux ≥ 5mm, asymptomatic patient, with normal radiological, microbiological and analytical studies. Disease criteria: Mantoux ≥ 5mm and any of the above pathological studies. Mediastinal ultrasound was used as a complementary method of chest radiography (CXR). Computed tomography (CT) as the combined result of ultrasound and CXR was inconclusive.

RESULTS

Seventeen out of 412 students were infected and 16 with tuberculosis disease. In addition, 4 out-school contacts were diagnosed of tuberculosis.

CLINICAL MANIFESTATIONS

one erythema nodosum, one Henoch-Schönlein purpura, twelve with cough and fever nine. CXR results in patients: 3 normal, 7 inconclusive, and 10 with the following findings: 2 pneumonia, 2 pulmonary atelectasis, 2 primary complexes, 4 patients only with lymphadenopathy. All patients with normal or indeterminate CXR showed mediastinal lymphadenopathy visualized on ultrasound but 3 demonstrated by CT. Microbiological isolation: 6 cases (31%).

CONCLUSIONS

The number of infected patients was higher compared to other outbreaks There is great variability in the diagnostic approach to tuberculosis micro-epidemics. It is complex to differentiate between infection and disease. The clinical, laboratory and CXR are nonspecific. There are patients with normal CXR, pathological ultrasound and microbiological isolation. Mediastinal ultrasound can play an important role in the diagnosis and management of tuberculosis disease.

Circular RNAs and tuberculosis infection

Tuberculosis (TB) is a deadly infectious disease caused by Mycobacterium tuberculosis (Mtb) that affects the immune system chronically. Therefore, effective control and treatment of tuberculosis requires rapid and accurate diagnostic strategies. Tuberculosis has always been a global burden on health, social and economic systems due to the lack of standard curative and diagnostic (bio)markers. Accordingly, the management and monitoring of patients with active TB at the primary care level may be possible through new, rapid and cost-effective non-sputum-based diagnostic procedures. Biomarkers can help diagnose various diseases, including circular RNA (circRNA), which has recently been introduced as an endogenous, abundant and stable RNA in the cytoplasm with unique tissue specificity. There are frequent reports of circRNA involvement in many pathological and physiological processes in human beings. Recent studies have highlighted the presence of circRNAs in serum and their role as promising biomarkers in the diagnosis of the disease, potentially due to the continuous, stable, closed covalent circular structures and lack of easy degradation by nucleases. The purpose of this review article is to scrutinize the behavior of circulating plasma RNAs in relation to the pathogenesis and diagnosis of tuberculosis.

Treatment of tuberculosis infection in children

INTRODUCTION

Identifying and treating children with tuberculosis (TB) infection in both low and high-TB burden settings will decrease the incidence of TB disease worldwide. Areas covered: This review covers each of the available TB infection treatment options for children based on effectiveness, safety, tolerability and treatment completion rates. Six to 9 months of daily administered isoniazid is no longer the treatment of choice for many children with TB infection. Shorter, rifamycin based, TB infection treatment regimens are effective, safe and easier for children to complete. Fluroquinolone-based regimens are recommended for the treatment of children infected by a source case with drug-resistant TB. Directly observed therapy (DOT) programs improve childhood TB infection treatment completion rates. Expert commentary: As shorter, rifamycin-based, TB infection treatment regimens offer superior treatment success rate in both adults and children; the widespread use of these regimens has huge potential to decrease the burden of TB disease worldwide. The implementation of these programs will involve improving patient access to the medications, decreasing their cost to the patient, and the use of novel electronic methods to document patient treatment completion.

High Prevalence of tuberculosis infection among medical students in Makerere University, Kampala: results of a cross sectional study

Background

Uganda’s Ministry of Health registered a 12% increase in new Tuberculosis (TB) cases between 2001 and 2005. Of these, 20% were from Kampala district and most from Mulago national referral hospital where the largest and the oldest medical school is found. Medical students are likely to have an increased exposure to TB infection due to their training in hospitals compared to other university students. The study compared the prevalence of TB infection and associated factors among undergraduate medical and veterinary students in Makerere University, Uganda.

Methods

This was a cross-sectional study with 232 medical and 250 veterinary undergraduate students. Socio-demographic and past medical history data was collected using questionnaires. A tuberculin skin test was performed on the volar aspect of the left forearm. An induration ≥10 mm in diameter after 48-72 hrs was considered positive. Logistic regression was used to determine association of independent variables with TB infection.

Results

The prevalence of TB infection was higher in medical students (44.8%, 95% C.I= 38.4-51.3%) compared to veterinary students (35.2%, 95% C.I = 29.3-41.1%). The significant predictors of TB infection were: being a medical student (aOR=1.56, 95% CI = 1.05-2.31), male sex (aOR=1.75, 95% CI = 1.17-2.63), history of contact with a confirmed TB case (aOR=1.57, 95% CI = 1.06-2.31) and residing at home (aOR=2.08, 95% CI = 1.20-3.61). Among the medical students, having gone to a day compared to boarding high school (aOR=2.31, 95% CI = 1.06-5.04), involvement in extracurricular clinical exposure (aOR=3.39 95% CI = 1.60-7.16), male sex, residence at home, and history of contact with a TB case predicted TB infection.

Conclusion

Medical students have a higher prevalence of TB infection than veterinary students probably due to increased exposure during training. There is a need to emphasize TB infection control measures in hospitals and the general community.

Bronchoesophageal Fistula in the Setting of Tuberculosis Infection

Acquired bronchoesophageal fistula can have their origin in a benign or malign cause. Benign bronchoesophageal fistula is rare and often associated with nonspecific symptoms that may delay the correct diagnosis. The authors present a case of a bronchoesophageal fistula in a 57-year-old woman caused by tuberculosis infection.

Tuberculosis - Present Medication and Therapeutic Prospects

BACKGROUND

Tuberculosis (TB) has been present in the history of human civilization since time immemorial and has caused more deaths than any other infectious disease. It is still considered one of the ten most common epidemiologic causes of death in the world. As a transmissible disease, it is initiated by rod-shaped (bacillus) mycobacteria. The management of tuberculosis became possible owing to several discoveries beginning in 1882 with the isolation of the TB bacillus by Robert Koch. The diagnosis of TB was enabled by finding a staining method for TB bacteria identification (1883). It was soon realized that a large-scale policy for the treatment and prevention of tuberculosis was necessary, which resulted in the foundation of International Union against Tuberculosis and Lung Diseases (1902). An antituberculosis vaccine was developed in 1921 and has been in therapeutic use since then. TB treatment regimens have changed over the decades and the latest recommendations are known as Directly Observed Treatment Short-course (DOTS, WHO 1993).

METHODS

A search of bibliographic databases was performed for peer-reviewed research literature. A focused review question and inclusion criteria were applied. Standard tools were used to assess the quality of retrieved papers.

RESULTS

A total of 112 papers were included comprising original publications and reviews. The paper overviews anti-TB drugs according to their mechanism of action. The chemical structure, metabolism and unwanted effects of such drugs have been discussed. The most recent treatment regimens and new drugs, including those in clinical trials, are also presented.

CONCLUSION

Despite a 22% decrease in the tuberculosis fatality rate observed between 2000 and 2015, the disease remains one of the ten prime causes of death worldwide. Increasing bacterial resistance and expensive, prolonged therapies are the main reasons for efforts to find effective drugs or antituberculosis regimens, especially to cure multidrug-resistant tuberculosis.

Interferon-gamma release assay performance in northeastern Brazil: influence of the IFNG+874 A>T polymorphism

Introduction

Latent tuberculosis infection diagnosis based on the release of interferon-gamma in cultures of peripheral blood cells stimulated with Mycobacterium tuberculosis antigens has replaced the tuberculin skin test in many countries with low tuberculosis prevalence. The IFN-γ production can be influenced by genetic polymorphisms, of which the IFNG + 874 (rs62559044) locus is the most studied. We investigated the possible influence of the IFNG + 874 A/T polymorphism on interferon-gamma test performance.

Methods

Patients diagnosed with pulmonary tuberculosis (75), volunteers with positive tuberculin skin test (70) and healthy volunteers with negative tuberculin skin test and no history of contact with tuberculosis (57) were evaluated regarding the IFNG + 874 genotype and the IFN-γ levels in whole blood cultures performed using an interferon-gamma commercial kit (QuantiFERON-TB^® Gold In-Tube).

Results

IFN-γ production was not influenced by the IFNG + 874 genotype, regardless of antigen or mitogen-based stimulation, which suggests that other genes may influence IFN-γ production in response to mycobacteria. The IFNG + 874 polymorphism was found to exert no influence over QFT-IT test sensitivity in our study.

Conclusions

The IFNG + 874 polymorphism was not shown to influence QuantiFERON-TB^® Gold In-Tube test performance in an admixed population from northeastern Brazil.

Isoniazid or rifampicin preventive therapy with and without screening for subclinical TB: a modeling analysis

BACKGROUND

Short-course, rifamycin-based regimens could facilitate scale-up of tuberculosis preventive therapy (TPT), but it is unclear how stringently tuberculosis (TB) disease should be ruled out before TPT use.

METHODS

We developed a state-transition model of a TPT intervention among two TPT-eligible cohorts: adults newly diagnosed with HIV in South Africa (PWH) and TB household contacts in Pakistan (HHCs). We modeled two TPT regimens-4 months of rifampicin [4R] or 6 months of isoniazid [6H]-comparing each to a reference of no intervention. Before initiating TPT, TB disease was excluded either through symptom-only screening or with additional radiographic screening that could detect subclinical TB but might limit access to the TPT intervention. TPT's potential curative effects on both latent and subclinical TB were modeled, as were both acquisitions of resistance and prevention of drug-resistant disease. Although all eligible individuals received the screening and/or TPT interventions, the modeled TB outcomes comprised only those with latent or subclinical TB that would have progressed to symptomatic disease if untreated.

RESULTS

When prescribed after only symptom-based TB screening (such that individuals with subclinical TB were included among TPT recipients), 4R averted 45 active (i.e., symptomatic) TB cases (95% uncertainty range 24-79 cases or 40-89% of progressions to active TB) per 1000 PWH [17 (9-29, 43-94%) per 1000 HHCs]; 6H averted 37 (19-66, 52-73%) active TB cases among PWH [13 (7-23, 53-75%) among HHCs]. With this symptom-only screening, for each net rifampicin resistance case added by 4R, 12 (3-102) active TB cases were averted among PWH (37 [9-580] among HHCs); isoniazid-resistant TB was also reduced. Similarly, 6H after symptom-only screening increased isoniazid resistance while reducing overall and rifampicin-resistant active TB. Screening for subclinical TB before TPT eliminated this net increase in resistance to the TPT drug; however, if the screening requirement reduced TPT access by more than 10% (the estimated threshold for 4R among HHCs) to 30% (for 6H among PWH), it was likely to reduce the intervention's overall TB prevention impact.

CONCLUSIONS

All modeled TPT strategies prevent TB relative to no intervention, and differences between TPT regimens or between screening approaches are small relative to uncertainty in the outcomes of any given strategy. If most TPT-eligible individuals can be screened for subclinical TB, then pairing such screening with rifamycin-based TPT maximizes active TB prevention and does not increase rifampicin resistance. Where subclinical TB cannot be routinely excluded without substantially reducing TPT access, the choice of TPT regimen requires weighing 4R's efficacy advantages (as well as its greater safety and shorter duration that we did not directly model) against the consequences of rifampicin resistance in a small fraction of recipients.

Clinical Features of Tuberculosis Pseudoaneurysm and Risk Factors for Mortality

OBJECTIVES

The objective of this study was to determine the clinical features of tuberculosis aneurysms and risk factors for mortality.

MATERIALS AND METHOD

We reviewed all case reports of tuberculous aneurysms in the English literature from January 2000 to December 2020. The clinical features and possible risk factors for mortality were recorded and analyzed.

RESULT

In total, 174 cases of tuberculosis aneurysms were identified. The morbidity of men was more than twice that of women. Male patients (51.47±20.67 years) were older than female patients (39.52±20.23 years), p<0.05. The rupture rate of women (69.2%) was higher than that of men (48.8%). TB-induced aneurysms often spontaneously ruptured 1.41-3.01 months after the onset of TB symptoms without any treatment, and Bacillus Calmette-Guerin (BCG)-induced aneurysms often spontaneously ruptured 10.51-26.49 months after BCG administration. The morbidity of large artery aneurysms was nearly twice that of middle artery aneurysms. However, middle artery aneurysms were more likely to rupture (75.4%) than large artery aneurysms (43.5%), p<0.05. The rupture rate of BCG-induced aneurysms (37.0%) was lower than that of TB-induced aneurysms, regardless of whether there was a TB history (56.7%) or not (57.7%). Symptoms of TB occurred in 63.2% of patients, but only 8.6% of patients had both symptoms of TB and aneurysmal mass effects. Pain was the most common atypical clinical manifestation (50.0%). The Cox proportional hazards regression analysis and Kaplan-Meier estimator showed that rupture and no combined therapy were risk factors for mortality.

CONCLUSION

Tuberculosis aneurysms seemingly shared the same demographic characteristics as common aneurysms. The clinical features of TB-induced aneurysms were different from those of BCG-induced aneurysms in terms of the aneurysm loactation and rupture rate. Tuberculosis aneurysms may occur at any site of the cardiovascular system with a preponderance for large arteries. The changeable clinical manifestations were an important index for diagnosis, but focusing only on clinical manifestations may lead to a missed diagnosis. The combination of anti-TB medications and surgery before aneurysm rupture may provide the best prognosis.

Can we treat bladder cancer with intravesical Bacillus Calmette-Guerin in patients with prior tuberculosis infection? A population-based cohort study

Background

Intravesical bacillus Calmette-Guerin (BCG) therapy is the treatment of choice for patients with T1 or high-grade superficial bladder cancer or those with carcinoma in situ after transurethral resection. A personal history of tuberculosis infection has been viewed as a relative contraindication for BCG therapy, because it may increase the risk of complications or decrease the treatment effectiveness. We determined the safety and efficacy of intravesical BCG treatment for patients with prior tuberculosis infection by analyzing the data obtained from the National Health Insurance Research Database in Taiwan.

Methods

We included patients who were newly diagnosed with bladder cancer from 2000 to 2009 and who received adjuvant intravesical BCG therapy within 3 months after the surgery. We excluded those who developed upper urinary tract cancer during the study period. Disease recurrence, disease progression, and major adverse effects were compared between patients with and without a prior diagnosis of tuberculosis infection until December 31, 2011.

Results

Among the 3915 patients included, 187 (4.8%) had been previously diagnosed with tuberculosis infection. The proportion of men (84.0% versus 76.9%) and older patients was higher in the group with a prior tuberculosis infection than in those without a prior tuberculosis infection. Significant differences in disease recurrence (20.3% versus 22.8%; hazard ratio [HR], 0.87; 95% confidence interval [CI], 0.63–1.21, p = 0.404) or disease progression (10.2% versus 12.8%, HR, 0.74; 95% CI, 0.46–1.17, p = 0.191) were not observed between the two groups. None of the patients with a prior tuberculosis infection had severe urinary tract infections, whereas four (0.1%) patients without such an infection developed severe urinary tract infections.

Conclusion

A prior tuberculosis infection did not affect the treatment efficacy or safety of intravesical BCG treatment. The efficacy and safety of intravesical BCG therapy are comparable between bladder cancer patients with and without prior tuberculosis infections.

Gaps in the care cascade for screening and treatment of refugees with tuberculosis infection in Middle Tennessee: a retrospective cohort study

BACKGROUND

Treatment of tuberculosis infection (TBI) in individuals at high risk for tuberculosis (TB) disease is a priority for TB elimination in the US. Newly arrived refugees in Middle Tennessee are screened for TBI, but factors associated with gaps in the TBI care cascade are not well characterized.

METHODS

We assessed the TBI care cascade from US entry to completion of treatment for refugees who resettled in Middle Tennessee from 2012 through 2016. We assessed factors associated with treatment initiation and completion using logistic regression models.

RESULTS

Of 6776 refugees who completed initial health screening, 1681 (25%) screened positive for TBI, 1208 were eligible for treatment, 690 started treatment, and 432 completed treatment. Male sex (Odds Ratio [OR]: 1.42; 95% Confidence Interval [CI]: 1.06, 1.89) and screening with interferon gamma release assay compared to tuberculin skin test (OR: 2.89; 95% CI: 1.59, 5.27) were associated with increased treatment initiation; living farther away from TB clinic was associated with decreased treatment initiation (OR: 0.91; 95% CI: 0.83, 0.99). Existing diabetes (OR: 7.27; 95% CI: 1.93, 27.30), receipt of influenza vaccination (OR: 1.65; 95% CI: 1.14, 2.40) and region of origin from South-Eastern or Southern Asia (ORSEAsia: 2.30; 95% CI: 1.43, 3.70; ORSAsia: 1.64; 95% CI: 1.02, 2.64) were associated with increased treatment completion. Six refugees developed TB disease after declining (n = 4) or partially completing (n = 2) TBI treatment; none who completed treatment developed TB disease.

CONCLUSIONS

We determined gaps in the TBI care cascade among refugees in Middle Tennessee. Further assessment of barriers to treatment initiation and completion and interventions to assist refugees are warranted to improve these gaps and prevent TB disease.

[Application of two-step approach for tuberculosis infection testing in tuberculosis control in schools]

Latent tuberculosis infection (LTBI) testing and treatment in high risk populations is an important tool for tuberculosis control. In China, tuberculin skin test (TST) has been recommended as a primary testing method for Mycobacterium tuberculosis (MTB) infection in new students and close contacts in schools, which laid a solid foundation for the early case finding and management. However, Due to the influence of multiple factors including BCG vaccination and nontuberculous mycobacteria infection, TST showed limitations in specificity for MTB infection detection. Guidelines issued by other countries showed that using the two-step approach (TST-IGRA) has advantages in improving diagnostic accuracy as compared with using TST alone. From the perspective of precise intervention, two-step approach for MTB infection testing might be a favorable choice for tuberculosis control in schools in China.

[Septic shock in a female patient with miliary tuberculosis]

This article reports the fulminant course of a pneumogenic sepsis with severe ARDS (acute respiratory failure) in a 36-year-old female Indian patient, who died within 14 h after admission to the intensive care unit due to a multiorgan failure. During treatment the diagnosis of a miliary tuberculosis was suspected but was only confirmed by the autopsy. Due to high hygiene standards, miliary tuberculosis as the cause of septic shock is rare in Europe. Only 1-2% of the patients with pulmonary miliary tuberculosis develop an ARDS with a mortality of 60-90%. Based on this case the diagnostics as well as treatment of the patient are described. Furthermore, the management of an open tuberculosis on an intensive care unit is explained.

[Interpretation of tuberculosis and hepatitis screening before immunosuppressive treatment]

An unrecognized latent tuberculosis infection (LTBI) may be reactivated under immunosuppressive therapy and become life threatening. Diagnosing LTBI requires the combination of targeted patient history and physical examination with the results of an interferon-gamma release assay (IGRA) and in addition, a chest X‑ray is needed to rule out active tuberculosis. Established therapies for LTBI reduce the reactivation risk by approximately 80%. For the initial screening of an HBV infection HBsAg and anti-HBc are determined. Hereby, HBsAg carriers (high HBV reactivation risk, indications for antiviral prophylaxis) and serologically resolved HBV infections (low HBV reactivation risk, use of prophylaxis only in high-risk immunosuppression) can be reliably detected. A previously unrecognized HCV infection, with an increased risk of developing liver cirrhosis during immunosuppression, can be detected in screening by anti-HCV antibodies and be successfully treated with antivirals without interferon.

Tuberculosis infection versus anti-tumor necrosis factor therapy: screening challenges in psoriatic patients

OBJECTIVES

The aim of this study was to analyze the performance of the tuberculin skin test (TST) for screening and monitoring patients treated with anti-tumor necrosis factor agents, in a high-incidence area.

METHODS

A 3-year retrospective study was carried out on 268 subjects. The study included 68 patients with moderate-to-severe psoriasis, screened for latent tuberculosis infection (LTBI) and subjects without psoriasis (100 adults and 100 children) with close contact with infected individuals.

RESULTS

Positive tuberculin skin test (TST) results (induration >5 mm) were observed in 70.5% (48/68) of patients with psoriasis, higher than those observed in subjects with suspicion of tuberculosis or with close contact with infected individuals: 51% (51/100) in the adult group and 30% (30/100) in the children group.

CONCLUSIONS

These results show that the prevalence of LTBI evaluated with the TST in the psoriatic group is higher than in subjects without psoriasis.

LIMITATION

The positive reactions were not confirmed by other verification methods.

Programmatic management of tuberculosis preventive therapy: Past, present, future

BACKGROUND

Tuberculosis (TB) infection (TBI) is an emerging public health priority, involving about one-fourth of the world population. Because patients with TBI are the reservoir for TB, stopping the progression to active disease by preventive treatment is one of the main interventions needed to achieve TB elimination. As of today, the proportion of people with TBI receiving treatment is minimal at the global level, mostly because current international policies recommend systematic testing and treatment for less than 2% of infected people.

PRESENT

FACTS AND GAPS: The programmatic management of TB preventive treatment involves a set of cascading interventions, of which the effectiveness is limited by the poor predictivity of diagnostic tests, the length and the potential toxicity of treatment, and the suboptimal prioritization within global policies. Partly because of this, competing priorities and the lack of adequate funding are significant barriers for scale-up, particularly in low- and middle-income countries.

MONITORING AND EVALUATION

To date, there is no universal system of monitoring and evaluation for the programmatic management of TB preventive treatment elements, and just a few countries use the standard recording and reporting tools, contributing to leaving TBI a neglected condition.

CONCLUSION

Better financed research and resources reallocation are essential steps to progress toward TB elimination worldwide.