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Rocco JM, Zhou Y, Liu NS, Laidlaw E, Galindo F, Anderson MV, Rupert A, Lage SL, Ortega-Villa AM, Yu S, Lisco A, Manion M, Vassiliou GS, Dunbar CE, Sereti I. Clonal hematopoiesis in people with advanced HIV and associated inflammatory syndromes. JCI Insight 2024; 9:e174783. [PMID: 38564303 DOI: 10.1172/jci.insight.174783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 03/21/2024] [Indexed: 04/04/2024] Open
Abstract
People with HIV (PWH) have a higher age-adjusted mortality due to chronic immune activation and age-related comorbidities. PWH also have higher rates of clonal hematopoiesis (CH) than age-matched non-HIV cohorts; however, risk factors influencing the development and expansion of CH in PWH remain incompletely explored. We investigated the relationship between CH, immune biomarkers, and HIV-associated risk factors (CD4+ and CD8+ T cells, nadir CD4+ count, opportunistic infections [OIs], and immune reconstitution inflammatory syndrome [IRIS]) in a diverse cohort of 197 PWH with median age of 42 years, using a 56-gene panel. Seventy-nine percent had a CD4+ nadir below 200 cells/μL, 58.9% had prior OIs, and 34.5% had a history of IRIS. The prevalence of CH was high (27.4%), even in younger individuals, and CD8+ T cells and nadir CD4+ counts strongly associated with CH after controlling for age. A history of IRIS was associated with CH in a subgroup analysis of patients 35 years of age and older. Inflammatory biomarkers were higher in CH carriers compared with noncarriers, supporting a dysregulated immune state. These findings suggest PWH with low nadir CD4+ and/or inflammatory complications may be at high risk of CH regardless of age and represent a high-risk group that could benefit from risk reduction and potentially targeted immunomodulation.
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Affiliation(s)
- Joseph M Rocco
- National Institute of Allergy and Infectious Diseases, and
| | - Yifan Zhou
- Translational Stem Cell Biology Branch, National Heart, Lung and Blood Institute, NIH, Bethesda, Maryland, USA
- Wellcome-MRC Cambridge Stem Cell Institute, University of Cambridge, Puddicombe Way, Cambridge, United Kingdom
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, Cambridge, United Kingdom
| | - Nicholas S Liu
- Translational Stem Cell Biology Branch, National Heart, Lung and Blood Institute, NIH, Bethesda, Maryland, USA
- Department of Biology, Brown University, Providence, Rhode Island, USA
| | | | | | | | - Adam Rupert
- Leidos Biomedical Research, Inc, Frederick, Maryland, USA
| | - Silvia L Lage
- National Institute of Allergy and Infectious Diseases, and
| | | | - Shiqin Yu
- Translational Stem Cell Biology Branch, National Heart, Lung and Blood Institute, NIH, Bethesda, Maryland, USA
| | - Andrea Lisco
- National Institute of Allergy and Infectious Diseases, and
| | - Maura Manion
- National Institute of Allergy and Infectious Diseases, and
| | - George S Vassiliou
- Wellcome-MRC Cambridge Stem Cell Institute, University of Cambridge, Puddicombe Way, Cambridge, United Kingdom
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, Cambridge, United Kingdom
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust (CUH), Cambridge, United Kingdom
| | - Cynthia E Dunbar
- Translational Stem Cell Biology Branch, National Heart, Lung and Blood Institute, NIH, Bethesda, Maryland, USA
| | - Irini Sereti
- National Institute of Allergy and Infectious Diseases, and
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French MA. The Immunopathogenesis of Immune Reconstitution Inflammatory Syndrome Has Become Clearer, but More Complex. J Infect Dis 2023; 228:106-110. [PMID: 37040572 DOI: 10.1093/infdis/jiad100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 04/07/2023] [Indexed: 04/13/2023] Open
Affiliation(s)
- Martyn A French
- School of Biomedical Sciences, The University of Western Australia, Perth, Australia
- Immunology Division, PathWest Laboratory Medicine, Perth, Australia
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Lage SL, Wong CS, Amaral EP, Sturdevant D, Hsu DC, Rupert A, Wilson EMP, Qasba SS, Naqvi NS, Laidlaw E, Lisco A, Manion M, Sereti I. Classical complement and inflammasome activation converge in CD14highCD16- monocytes in HIV associated TB-immune reconstitution inflammatory syndrome. PLoS Pathog 2021; 17:e1009435. [PMID: 33788899 PMCID: PMC8041190 DOI: 10.1371/journal.ppat.1009435] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 04/12/2021] [Accepted: 03/01/2021] [Indexed: 02/07/2023] Open
Abstract
Inflammasome-derived cytokines, IL-1β and IL-18, and complement cascade have been independently implicated in the pathogenesis of tuberculosis (TB)-immune reconstitution inflammatory syndrome (TB-IRIS), a complication affecting HIV+ individuals starting antiretroviral therapy (ART). Although sublytic deposition of the membrane attack complex (MAC) has been shown to promote NLRP3 inflammasome activation, it is unknown whether these pathways may cooperatively contribute to TB-IRIS. To evaluate the activation of inflammasome, peripheral blood mononuclear cells (PBMCs) from HIV-TB co-infected patients prior to ART and at the IRIS or equivalent timepoint were incubated with a probe used to assess active caspase-1/4/5 followed by screening of ASC (apoptosis-associated speck-like protein containing a CARD domain) specks as a readout of inflammasome activation by imaging flow cytometry. We found higher numbers of monocytes showing spontaneous caspase-1/4/5+ASC-speck formation in TB-IRIS compared to TB non-IRIS patients. Moreover, numbers of caspase-1/4/5+ASC-speck+ monocytes positively correlated with IL-1β/IL-18 plasma levels. Besides increased systemic levels of C1q and C5a, TB-IRIS patients also showed elevated C1q and C3 deposition on monocyte cell surface, suggesting aberrant classical complement activation. A clustering tSNE analysis revealed TB-IRIS patients are enriched in a CD14highCD16- monocyte population that undergoes MAC deposition and caspase-1/4/5 activation compared to TB non-IRIS patients, suggesting complement-associated inflammasome activation during IRIS events. Accordingly, PBMCs from patients were more sensitive to ex-vivo complement-mediated IL-1β secretion than healthy control cells in a NLRP3-dependent manner. Therefore, our data suggest complement-associated inflammasome activation may fuel the dysregulated TB-IRIS systemic inflammatory cascade and targeting this pathway may represent a novel therapeutic approach for IRIS or related inflammatory syndromes. Tuberculosis (TB) associated-immune reconstitution inflammatory syndrome (TB-IRIS) is a clinical complication affecting HIV+ individuals previously co-infected with Mycobacterium tuberculosis (Mtb), upon antiretroviral therapy (ART) initiation. TB-IRIS is characterized by an exacerbated inflammatory response and can be associated with high morbidity and mortality rates in resource-limited countries with high TB prevalence. So far, there is no targeted TB-IRIS therapy, and corticosteroids are frequently used to prevent or alleviate IRIS related-symptoms. Here we found inflammasome activation (i.e. caspase1/4/5+ASC speck complex formation) on circulating classical CD14highCD16- monocytes may contribute to TB-IRIS immunopathology, since it correlates with pro-inflammatory cytokine plasma levels and its decay is associated with dampening in IRIS-related symptoms promoted by anti-inflammatory therapy. We also found TB-IRIS monocytes display higher surface complement deposition, being more sensitive to external complement-mediated NLRP3 inflammasome activation than healthy control cells. In fact, complement MAC molecule C9 and caspase-1/4/5 activation were associated on classical monocytes in TB-IRIS patients, suggesting complement-mediated inflammasome activation may lead to a positive feedback loop in the inflammatory responses observed in TB-IRIS. Therefore, our findings support that complement-NLRP3/ASC/caspase1/4/5 axis may be considered as a potential target for host-directed therapy of TB-IRIS.
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Affiliation(s)
- Silvia Lucena Lage
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States of America
- * E-mail: (SLL); (IS)
| | - Chun-Shu Wong
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States of America
| | - Eduardo Pinheiro Amaral
- Immunobiology Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States of America
| | - Daniel Sturdevant
- RML Genomics Unit, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, MT, United States of America
| | - Denise C. Hsu
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States of America
| | - Adam Rupert
- Applied and Developmental Research Directorate, AIDS Monitoring Laboratory, Leidos Biomedical Research, Inc, Frederick, MD, United States of America
| | - Eleanor M. P. Wilson
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States of America
| | - S. Sonia Qasba
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States of America
| | - Nuha Sultana Naqvi
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States of America
| | - Elizabeth Laidlaw
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States of America
| | - Andrea Lisco
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States of America
| | - Maura Manion
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States of America
| | - Irini Sereti
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States of America
- * E-mail: (SLL); (IS)
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4
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Goovaerts O, Massinga-Loembé M, Ondoa P, Ceulemans A, Worodria W, Mayanja-Kizza H, Colebunders R, Kestens L. Lack of elevated pre-ART elastase-ANCA levels in patients developing TB-IRIS. PLoS One 2020; 15:e0244800. [PMID: 33382831 PMCID: PMC7775098 DOI: 10.1371/journal.pone.0244800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 12/16/2020] [Indexed: 11/19/2022] Open
Abstract
Background Tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) in HIV-TB co-infected patients receiving antiretroviral therapy (ART) has been linked to neutrophil activation. Anti-neutrophil cytoplasmic antibodies (ANCAs) are also associated with neutrophil activation. Since ANCAs are reportedly skewed in TB and HIV infections, we investigated plasma levels of 7 ANCAs in TB-IRIS patients. Methods We retrospectively compared 17 HIV-TB patients who developed TB-IRIS with controls of similar CD4 count, age and gender who did not (HIV+TB+ n = 17), HIV-infected patients without TB (HIV+TB-, n = 17) and 10 HIV-negative (HIV-TB-) controls. Frozen plasma was collected before ART, at 3 and 9 months of ART, and examined by ELISA for levels of 7 ANCAs directed against; Proteinase 3 (PR3), Myeloperoxidase (MPO), Permeability-increasing protein (BPI), Elastase, Cathepsin, Lysozyme, and Lactoferrin. Results Compared to HIV+TB+ controls, pre-ART anti-elastase levels were lower in TB-IRIS patients (p = 0.026) and HIV-TB- controls (p = 0.044), whereas other ANCAs did not show significant differences between groups at any time point. A significant decrease over time could be observed in TB-IRIS patients during ART for anti -PR3 (p = 0.027), -lysozyme (p = 0.011), and -lactoferrin (p = 0.019). Conversely, HIV+TB+ controls showed a significant decrease over time for anti -MPO (p = 0.002), -lyzosyme (p = 0.002) and -elastase (p < 0.001). Conclusion The lack of elevated anti-elastase levels in TB-IRIS patients as opposed to HIV+TB+ controls correspond to previous findings of lowered immune capacity in patients that will develop TB-IRIS. This may suggest a specific role for anti-elastase, elastase or even matrix-metalloproteinases in TB-IRIS. The precise dynamics of neutrophil activation in HIV-TB merits further investigation and could provide more insight in the early mechanisms leading up to TB-IRIS.
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Affiliation(s)
- Odin Goovaerts
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- * E-mail:
| | - Marguerite Massinga-Loembé
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Centre de Recherches Médicales de Lambaréné (CERMEL), Albert Schweitzer Hospital, Lambarene, Gabon
- Institut für Tropenmedizin,Universität Tübingen, Tübingen, Germany
| | - Pascale Ondoa
- African Society for Laboratory Medicine, Addis Ababa, Ethiopia
- Amsterdam Institute of Global Health and Development, Academic Medical Center, Department of Global Health, University of Amsterdam, Amsterdam, The Netherlands
| | - Ann Ceulemans
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - William Worodria
- Department of Medicine, Mulago Hospital, Kampala, Uganda
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Infectious Diseases Network for Treatment and Research in Africa (INTERACT), Kampala, Uganda
| | - Harriet Mayanja-Kizza
- Department of Medicine, Mulago Hospital, Kampala, Uganda
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Luc Kestens
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
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5
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Zhang YB, Liu SJ, Hu ZD, Zhou JX, Wang YZ, Fang B, Wong KW, Xia F. Increased Th17 activation and gut microbiota diversity are associated with pembrolizumab-triggered tuberculosis. Cancer Immunol Immunother 2020; 69:2665-2671. [PMID: 32761425 DOI: 10.1007/s00262-020-02687-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 07/30/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION A hypersensitivity response akin to immune reconstitution inflammatory syndrome (IRIS) has been proposed as a mechanism responsible for anti-PD-1 therapy-induced tuberculosis. IRIS is associated with enhanced activation of IL-17A-expressing CD4 + T cells (Th17). Gut microbiota is thought to be linked to pulmonary inflammation through the gut-lung axis. MATERIALS AND METHODS We used ImmuCellAI to investigate the T cell population in lung cancer and tuberculosis samples. Then, we applied flow cytometry to monitor the expression levels of the Th17 cell activation marker CD38 in the peripheral blood of a patient experiencing adverse events, including tuberculosis, in response to pembrolizumab. The gut microbiome was examined by 16S rRNA sequencing to examine the alterations caused by pembrolizumab. RESULTS The percentage of Th17 cells was increased in both lung cancer and tuberculosis. FACS analysis showed that pembrolizumab induced substantial CD38 expression in Th17 cells. The patient's fecal samples showed that the diversity of the gut microbiota was significantly increased in response to the pembrolizumab cycle. One enriched genus was Prevotella, which has previously been linked to lung inflammation and Th17 immune activation. DISCUSSION The observed Th17 activation in our patient was consistent with a role of Th17-mediated IRIS in pembrolizumab-triggered tuberculosis. Pembrolizumab might trigger airway inflammation with a Th17 phenotype through microbiota interactions in the gut-lung axis.
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Affiliation(s)
- Yun-Bin Zhang
- Shanghai Public Health Clinical Center, Key Laboratory of Medical Molecular Virology, School of Basic Medical Sciences, Fudan University, Shanghai, China
| | - Shi-Jia Liu
- Department of Pulmonary Disease, PLA 905 Hospital, 9585 Humin Road, Shanghai, 200235, China
| | - Zhi-Dong Hu
- Shanghai Public Health Clinical Center, Key Laboratory of Medical Molecular Virology, School of Basic Medical Sciences, Fudan University, Shanghai, China
| | - Ji-Xue Zhou
- Department of Pulmonary Disease, PLA 905 Hospital, 9585 Humin Road, Shanghai, 200235, China
| | - Yin-Zhen Wang
- Department of Pulmonary Disease, PLA 905 Hospital, 9585 Humin Road, Shanghai, 200235, China
| | - Bing Fang
- Department of Pulmonary Disease, PLA 905 Hospital, 9585 Humin Road, Shanghai, 200235, China
| | - Ka-Wing Wong
- Shanghai Public Health Clinical Center, Key Laboratory of Medical Molecular Virology, School of Basic Medical Sciences, Fudan University, Shanghai, China.
| | - Fan Xia
- Department of Pulmonary Disease, PLA 905 Hospital, 9585 Humin Road, Shanghai, 200235, China.
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Santana LM, Valadares EA, Ferreira-Júnior CU, Santos MF, Albergaria BH, Rosa-Júnior M. CD8 + T-lymphocyte Encephalitis: A Systematic Review. AIDS Rev 2020; 22:112-122. [PMID: 32180590 DOI: 10.24875/aidsrev.20000132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 02/12/2020] [Indexed: 11/17/2022]
Abstract
The increase of CD8 + T lymphocytes in the perivascular spaces of patients with HIV encephalopathy has been reported in some studies. CD8 + T lymphocyte encephalitis was first described in 2013 and then a few other similar cases were published. We proposed to analyze the clinical, MR imaging, and histopathology findings of CD8 + T lymphocyte encephalitis. A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyzes protocol using the PubMed, Scopus, Lilacs, and IBECS databases up to February 3, 2018. Seven articles were included, two case series and five case reports. A total of 19 individuals were evaluated. MRI showed alterations in the white matter signal in all cases. Histopathology showed a predominance of CD8 + T lymphocytes. The findings described so far may resemble the inflammatory immune reconstitution syndrome. New studies on the subject are needed in an attempt to characterize the differences between these two entities.
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Affiliation(s)
- Larissa M Santana
- Department of Radiology, Hospital Universitário Cassiano Antônio de Moraes da Universidade Federal do Espírito Santo - HUCAM/UFES/EBSERH, Brazil
| | - Eduardo A Valadares
- Department of Radiology, Hospital Universitário Cassiano Antônio de Moraes da Universidade Federal do Espírito Santo - HUCAM/UFES/EBSERH, Brazil
| | - Carlos U Ferreira-Júnior
- Department of Infectious Diseases, Hospital Universitário Cassiano Antônio de Moraes da Universidade Federal do Espírito Santo - HUCAM/UFES/EBSERH, Brazil
| | - Maria F Santos
- Department of Pathology, Hospital Universitário Cassiano Antônio de Moraes da Universidade Federal do Espírito Santo - HUCAM/UFES/EBSERH, Brazil
| | - Ben-Hur Albergaria
- Department of Social Medicine, Federal University of Espírito Santo, and Osteoporosis Research and Diagnosis Center - CEDOES, Brazil
| | - Marcos Rosa-Júnior
- Department of Neuroradiology, Hospital Universitário Cassiano Antônio de Moraes da Universidade Federal do Espírito Santo - HUCAM/UFES/EBSERH. Vitória, Espírito Santo, Brazil
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Silva CAM, Graham B, Webb K, Ashton LV, Harton M, Luetkemeyer AF, Bokatzian S, Almubarak R, Mahapatra S, Hovind L, Kendall MA, Havlir D, Belisle JT, De Groote MA. A pilot metabolomics study of tuberculosis immune reconstitution inflammatory syndrome. Int J Infect Dis 2019; 84:30-38. [PMID: 31009738 PMCID: PMC6613934 DOI: 10.1016/j.ijid.2019.04.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/10/2019] [Accepted: 04/13/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Diagnosis of paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is challenging and new tools are needed for early diagnosis as well as to understand the biochemical events that underlie the pathology in TB-IRIS. METHODS Plasma samples were obtained from participants from a randomized HIV/TB treatment strategy study (AIDS Clinical Trials Group [ACTG] A5221) with (n = 26) and without TB-IRIS (n = 22) for an untargeted metabolomics pilot study by liquid-chromatography mass spectrometry. The metabolic profile of these participants was compared at the study entry and as close to the diagnosis of TB-IRIS as possible (TB-IRIS window). Molecular features with p < 0.05 and log2 fold change ≥0.58 were submitted for pathway analysis through MetaboAnalyst. We also elucidated potential metabolic signatures for TB-IRIS using a LASSO regression model. RESULTS At the study entry, we showed that the arachidonic acid and glycerophospholipid metabolism were altered in the TB-IRIS group. Sphingolipid and linoleic acid metabolism were the most affected pathways during the TB-IRIS window. LASSO modeling selected a set of 8 and 7 molecular features with the potential to predict TB-IRIS at study entry and during the TB-IRIS window, respectively. CONCLUSION This study suggests that the use of plasma metabolites may distinguish HIV-TB patients with and without TB-IRIS.
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Affiliation(s)
- Carlos A M Silva
- Mycobacterial Research Laboratories, Fort Collins, CO, USA; Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO, USA
| | - Barbara Graham
- Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO, USA
| | - Kristofor Webb
- Mycobacterial Research Laboratories, Fort Collins, CO, USA
| | | | - Marisa Harton
- Mycobacterial Research Laboratories, Fort Collins, CO, USA
| | | | | | | | | | - Laura Hovind
- Frontier Science & Technology Research Foundation, Inc., Amherst, NY, USA
| | - Michelle A Kendall
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health Boston, MA, USA
| | - Diane Havlir
- University of California San Francisco, San Francisco, CA, USA
| | - John T Belisle
- Mycobacterial Research Laboratories, Fort Collins, CO, USA
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Cotton MF, Rabie H, Nemes E, Mujuru H, Bobat R, Njau B, Violari A, Mave V, Mitchell C, Oleske J, Zimmer B, Varghese G, Pahwa S. A prospective study of the immune reconstitution inflammatory syndrome (IRIS) in HIV-infected children from high prevalence countries. PLoS One 2019; 14:e0211155. [PMID: 31260455 PMCID: PMC6602181 DOI: 10.1371/journal.pone.0211155] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 05/31/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The immune reconstitution inflammatory syndrome (IRIS) in HIV-infected infants and young children is relatively understudied in regions endemic for HIV and TB. We aimed to describe incidence, clinical features and risk factors of pediatric IRIS in Sub-Saharan Africa and India. METHODS AND FINDINGS We conducted an observational multi-centred prospective clinical study from December 2010 to September 2013 in children <72 months of age recruited from public antiretroviral programs. The main diagnostic criterion for IRIS was a new or worsening inflammatory event after initiating antiretroviral therapy (ART). Among 198 participants, median age 1.15 (0.48; 2.21) years, 38 children (18.8%) developed 45 episodes of IRIS. Five participants (13.2%) had two IRIS events and one (2.6%) had 3 events. Main causes of IRIS were BCG (n = 21; 46.7%), tuberculosis (n = 10; 22.2%) and dermatological, (n = 8, 17.8%). Four TB IRIS cases had severe morbidity including 1 fatality. Cytomegalovirus colitis and cryptococcal meningitis IRIS were also severe. BCG IRIS resolved without pharmacological intervention. On multivariate logistic regression, the most important baseline associations with IRIS were high HIV viral load (likelihood ratio [LR] 10.629; p = 0.0011), recruitment at 1 site (Stellenbosch University) (LR 4.01; p = 0.0452) and CD4 depletion (LR 3.4; p = 0.0654). Significantly more non-IRIS infectious and inflammatory events between days 4 and 17 of ART initiation were noted in cases versus controls (35% versus 15.2%: p = 0.0007). CONCLUSIONS IRIS occurs commonly in HIV-infected children initiating ART and occasionally has severe morbidity. The incidence may be underestimated. Predictive, diagnostic and prognostic biomarkers are needed.
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Affiliation(s)
- Mark F. Cotton
- Department of Pediatrics & Child Health, Stellenbosch University, Tygerberg, South Africa
| | - Helena Rabie
- Department of Pediatrics & Child Health, Stellenbosch University, Tygerberg, South Africa
| | - Elisa Nemes
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease & Molecular Medicine and Division of Immunology, Pathology, University of Cape Town, Cape Town, South Africa
| | - Hilda Mujuru
- Department of Pediatrics, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Raziya Bobat
- Department of Pediatrics & Child Health, University of KwaZulu-Natal, Durban, South Africa
| | - Boniface Njau
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Avy Violari
- Department of Pediatrics & Child Health, Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Charles Mitchell
- Department of Pediatric Immunology, University of Miami, Miami, FL, United States of America
| | - James Oleske
- Department of Pediatrics & Child Health, Rutgers New Jersey Medical School, Newark, NJ, United States of America
| | - Bonnie Zimmer
- Frontier Science & Technology Research Foundation, Amherst, NY, United States of America
| | - George Varghese
- Department of Pediatrics & Child Health, University of Miami Miller School of Medicine, Miami, FL, United States of America
| | - Savita Pahwa
- Department of Pediatrics & Child Health, University of Miami Miller School of Medicine, Miami, FL, United States of America
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9
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Goovaerts O, Massinga-Loembé M, Ondoa P, Ceulemans A, Worodria W, Mayanja-Kizza H, Colebunders R, Kestens L. Increased KLRG1 and PD-1 expression on CD8 T lymphocytes in TB-IRIS. PLoS One 2019; 14:e0215991. [PMID: 31022273 PMCID: PMC6483230 DOI: 10.1371/journal.pone.0215991] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 04/11/2019] [Indexed: 12/23/2022] Open
Abstract
Background Tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is an inflammatory complication in HIV-TB co-infected patients receiving antiretroviral therapy (ART). The exact contribution of T cells, natural killer (NK) cells, and monocytes to TB-IRIS development remains unclear. Here, we studied the expression of exhaustion markers on lymphocytes at different intervals during ART. Methods We compared 13 HIV-TB patients who developed TB-IRIS with 13 patients who did not (HIV+TB+), 13 HIV-patients without TB (HIV+TB-) and 9 HIV/TB-negative controls (HIV-TB-). Patients did not differ in age, gender, or CD4-count prior to ART. Frozen peripheral blood mononuclear cells, collected before ART and during 3 months and 9 months of ART, were analysed using flow cytometry. We examined expression of KLRG1, PD-1 and IL-27R on CD4+ and CD8hi T cells, as well as CD3-negative CD8lo lymphocytes as an approximate subset of NK cells. In addition, expression of TLR2, TLR4, IL1RL1, and TRAILR on CD14+ monocytes were investigated. Results Prior to ART, TB-IRIS patients had higher percentages of CD8hi T cells that are KLRG1+PD-1+ compared to each control group (p≤0.034). Though PD-1 expression decreased during ART in all groups (p≤0.026), the percentage KLRG1+PD-1+CD8hi T cells remained higher in TB-IRIS patients after 3 months of ART (p≤0.013). Though these patterns were less pronounced in CD3-CD8lo lymphocytes, the percentage of KLRG1+ cells was higher in TB-IRIS patients prior to ART (p≤0.043). In contrast, no clear differences could be observed for CD4+ T cells or monocytes. Conclusion TB-IRIS is preceded by a high level of exhausted (KLRG1+PD-1+) CD8hi T cells, which persists during 3 months of ART. This trait is potentially mirrored in a subpopulation of NK cells, but not CD4+ T cells. Since a dysfunctional CD8+ lymphocyte compartment could predispose patients to TB-IRIS, the functional role of these cells prior to TB-IRIS development should be further explored.
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Affiliation(s)
- Odin Goovaerts
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- * E-mail:
| | - Marguerite Massinga-Loembé
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Centre de Recherches Médicales de Lambaréné (CERMEL), Albert Schweitzer Hospital, Lambarene, Gabon
- Institut für Tropenmedizin, Universität Tübingen, Tübingen, Germany
| | - Pascale Ondoa
- Department of Global Health and Amsterdam Institute for Global Health and Development, Academic Medical Centre, Amsterdam, The Netherlands
| | - Ann Ceulemans
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - William Worodria
- Department of Medicine, Mulago Hospital, Kampala, Uganda
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Infectious Diseases Network for Treatment and Research in Africa (INTERACT), Kampala, Uganda
| | - Harriet Mayanja-Kizza
- Department of Medicine, Mulago Hospital, Kampala, Uganda
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Robert Colebunders
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Luc Kestens
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
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Hoang E, Bartlett NL, Goyal MS, Schmidt RE, Clifford DB. Progressive multifocal leukoencephalopathy treated with nivolumab. J Neurovirol 2019; 25:284-287. [PMID: 30864100 PMCID: PMC6506384 DOI: 10.1007/s13365-019-00738-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 02/13/2019] [Accepted: 02/19/2019] [Indexed: 01/07/2023]
Abstract
Therapy for progressive multifocal leukoencephalopathy (PML) remains challenging since there are no antiviral therapies available for JC virus. Immune reconstitution has improved the prognosis in many settings where PML occurs, but it often is not possible in PML patients with hematologic malignancies. We describe the first biopsy proven PML case where the PD-1 inhibitor nivolumab appears to have stimulated immune activation resulting in effective control of PML in a patient with hematologic malignancy. This report supports further investigation of the utility of checkpoint inhibitors for treating PML where other immune reconstitution options are not available.
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Affiliation(s)
- Ethan Hoang
- Department of Neurology, Washington University in St. Louis, Box 8111, 660 South Euclid Avenue, Saint Louis, MO, 63110, USA
| | - Nancy L Bartlett
- Department of Medicine, Washington University in St. Louis, St Louis, MO, USA
| | - Manu S Goyal
- Department of Neurology, Washington University in St. Louis, Box 8111, 660 South Euclid Avenue, Saint Louis, MO, 63110, USA
- Department of Radiology, Washington University in St. Louis, St Louis, MO, USA
| | - Robert E Schmidt
- Department of Pathology and Immunology, Washington University in St. Louis, St Louis, MO, USA
| | - David B Clifford
- Department of Neurology, Washington University in St. Louis, Box 8111, 660 South Euclid Avenue, Saint Louis, MO, 63110, USA.
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11
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Yoon HA, Nakouzi A, Chang CC, Kuniholm MH, Carreño LJ, Wang T, Ndung’u T, Lewin SR, French MA, Pirofski LA. Association Between Plasma Antibody Responses and Risk for Cryptococcus-Associated Immune Reconstitution Inflammatory Syndrome. J Infect Dis 2019; 219:420-428. [PMID: 30010905 PMCID: PMC6325352 DOI: 10.1093/infdis/jiy447] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 07/13/2018] [Indexed: 01/12/2023] Open
Abstract
Background Initiation of antiretroviral therapy (ART) in human immunodeficiency virus (HIV)-infected individuals with cryptococcal meningitis places them at risk for Cryptococcus-associated immune reconstitution inflammatory syndrome (C-IRIS). The relationship between antibody immunity and C-IRIS risk has not been investigated. Methods We compared plasma levels of immunoglobulins, C. neoformans glucuronoxylomannan (GXM) capsule-specific and laminarin (Lam)-binding IgM and IgG, and percentages of peripheral blood total and memory B cells between 27 HIV-infected patients with CM who developed C-IRIS and 63 who did not, and evaluated associations of these parameters with risk of C-IRIS. Results Prior to initiation of ART, plasma IgM, Lam-binding IgM (Lam-IgM), Lam-IgG, and GXM-IgM levels were significantly lower in patients who developed C-IRIS than those who did not. Multivariate analysis revealed significant inverse associations between C-IRIS and IgM (P = .0003), Lam-IgM (P = .0005), Lam-IgG (P = .002), and GXM-IgM (P = .002) independent of age, sex, HIV viral load, CD4+ T-cell count, and cerebrospinal fluid fungal burden. There were no associations between C-IRIS and total or memory B cells. Discussion Antibody profiles that include plasma IgM, Lam-IgM, Lam-IgG, and/or GXM-IgM may have value in furthering our understanding of C-IRIS pathogenesis and hold promise as candidate biomarkers of C-IRIS risk.
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Affiliation(s)
- Hyun Ah Yoon
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Antonio Nakouzi
- Department of Microbiology and Immunology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Christina C Chang
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia
| | - Mark H Kuniholm
- Department of Epidemiology and Biostatistics, University at Albany, Rensselaer, New York
| | - Leandro J Carreño
- Millennium Institute on Immunology and Immunotherapy, Programa de Inmunología, Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Tao Wang
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Thumbi Ndung’u
- HIV Pathogenesis Programme, Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal
- Africa Health Research Institute, Durban, South Africa
- Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard University, Cambridge
- Max Planck Institute for Infection Biology, Berlin, Germany
| | - Sharon R Lewin
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia
- The Peter Doherty Institute for Infection and Immunity, University of Melbourne and Royal Melbourne Hospital
| | - Martyn A French
- University of Western Australia Medical School and School of Biomedical Sciences, Perth, Australia
| | - Liise-anne Pirofski
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
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Rowley MW, Patel A, Zhou W, Wong M, Seetharam AB. Immune Reconstitution Syndrome with Initiation of Treatment of HBV/HIV Co-infection: Activity Flare associated with E antigen Seroconversion. Ann Hepatol 2019; 18:220-224. [PMID: 31113594 DOI: 10.5604/01.3001.0012.7918] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 07/17/2017] [Indexed: 02/04/2023]
Abstract
Immune reconstitution syndrome is a recognized complication with initiation of highly active antiretroviral therapy for acquired immune deficiency syndrome patients co-infected with hepatitis B. Hepatitis B flares are seen in 20%-25% of patients after initiation of highly active antiretroviral therapy, an estimated 1%-5% of whom develop clinical hepatitis. We present a case of highly active antiretroviral therapy initiation for HIV that led to a flare of HBV activity despite antiviral therapy directed towards both. Liver biopsy and longitudinal serologic evaluation lend support to the hypothesis that the flare in activity was representative of IRIS. Importantly, we document eAg/eAb seroconversion with the IRIS phenomenon.
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Affiliation(s)
- Michael W Rowley
- Department of Internal Medicine, Banner University Medical Center Phoenix, Phoenix, AZ, USA; Transplant and Advanced Liver Disease Center, Banner University Medical Center Phoenix, Phoenix, AZ, USA.
| | - Amitkumar Patel
- Department of Gastroenterology, Banner University Medical Center Phoenix, Phoenix, AZ, USA; Transplant and Advanced Liver Disease Center, Banner University Medical Center Phoenix, Phoenix, AZ, USA
| | - Wendi Zhou
- Department of Pathology, Banner University Medical Center Phoenix, Phoenix, AZ, USA; University of Arizona College of Medicine Phoenix, Phoenix, AZ, USA
| | - Mark Wong
- Transplant and Advanced Liver Disease Center, Banner University Medical Center Phoenix, Phoenix, AZ, USA; University of Arizona College of Medicine Phoenix, Phoenix, AZ, USA
| | - Anil B Seetharam
- Transplant and Advanced Liver Disease Center, Banner University Medical Center Phoenix, Phoenix, AZ, USA; University of Arizona College of Medicine Phoenix, Phoenix, AZ, USA
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Abstract
Immune reconstitution inflammatory syndrome (IRIS) describes a syndrome of aberrant reconstituted immunity, often in association with HIV infection, beginning with a normalization of CD4+ T-cell counts resulting in a dysregulated immune response against an infecting opportunistic pathogen and the host. In this chapter, we discuss the unique nature of IRIS when present in the central nervous system (CNS IRIS) and the changes experienced with each host pathogen and its unique influence on the immune system. Consensus on the mechanism of action of the immune system in IRIS pathology is less clear and multiple theories have been proposed. Here we explore the early history of the term IRIS, proposed mechanisms and animal models, as well as common CNS pathogens associated with IRIS, and management strategies.
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Affiliation(s)
- Lauren Bowen
- Section of Infections of the Nervous System, National Institute for Neurologic Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
| | - Avindra Nath
- Section of Infections of the Nervous System, National Institute for Neurologic Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States.
| | - Bryan Smith
- Section of Infections of the Nervous System, National Institute for Neurologic Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
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14
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George V, Harrison L, Roach M, Li XD, Tierney C, Fischl MA, Aberg J, Tebas P, Asmuth DM, Pollard RB, Godfrey C, Pahwa S. Associations of Plasma Cytokine and Microbial Translocation Biomarkers With Immune Reconstitution Inflammatory Syndrome. J Infect Dis 2017; 216:1159-1163. [PMID: 29040604 PMCID: PMC5853564 DOI: 10.1093/infdis/jix460] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 09/13/2017] [Indexed: 01/12/2023] Open
Abstract
A nested case-cohort study was performed in participants of a clinical trial of first-line human immunodeficiency virus treatments to investigate plasma biomarkers of inflammation and microbial translocation for their association with immune reconstitution inflammatory syndrome (IRIS). Fifty-one of 1452 participants with baseline CD4 count <350 cells/μL developed IRIS. Plasma from 51 IRIS cases, including 6 stratified by preenrollment CD4 count ≤200 cells/μL, were analyzed and compared to 94 non-IRIS controls. At baseline, CXCL10, lipopolysaccharide, soluble CD14, 16S ribosomal DNA, and interferon-α2 were associated with greater risk of IRIS. Systemic inflammation through persistent monocyte activation and microbial translocation appear to be important in IRIS pathogenesis.
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Affiliation(s)
- Varghese George
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Florida
| | - Linda Harrison
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public, Boston, Massachusetts
| | - Margaret Roach
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Florida
| | - Xiao-Dong Li
- Department of Internal Medicine, University of California, Davis School of Medicine, Sacramento
| | - Camlin Tierney
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public, Boston, Massachusetts
| | - Margaret A Fischl
- AIDS Clinical Research Unit, Department of Medicine, University of Miami Miller School of Medicine, Florida
| | - Judith Aberg
- Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Pablo Tebas
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - David M Asmuth
- Department of Internal Medicine, University of California, Davis School of Medicine, Sacramento
| | - Richard B Pollard
- Department of Internal Medicine, University of California, Davis School of Medicine, Sacramento
| | - Catherine Godfrey
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Savita Pahwa
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Florida
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15
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Yap SH, Abdullah NK, McStea M, Takayama K, Chong ML, Crisci E, Larsson M, Azwa I, Kamarulzaman A, Leong KH, Woo YL, Rajasuriar R. HIV/Human herpesvirus co-infections: Impact on tryptophan-kynurenine pathway and immune reconstitution. PLoS One 2017; 12:e0186000. [PMID: 29016635 PMCID: PMC5633182 DOI: 10.1371/journal.pone.0186000] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 09/22/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Co-infections with human herpesvirus (HHV) have been associated with residual chronic inflammation in antiretroviral (ART)-treated human immunodeficiency virus (HIV)-infected individuals. However, the role of HHV in modulating the tryptophan-kynurenine pathway and clinical outcomes in HIV-infected individuals is poorly understood. Thus, we investigated the seroprevalence of four common HHVs among treated HIV-infected participants and their impact on kynurenine/tryptophan (K/T) ratio and long-term CD4 T-cell recovery in HIV/HHV co-infected participants. METHOD In this cross-sectional study, HIV-infected participants receiving suppressive ART for a minimum of 12 months were recruited from the University Malaya Medical Centre (UMMC), Malaysia. Stored plasma was analyzed for CMV, VZV, HSV-1 and HSV-2 IgG antibody levels, immune activation markers (interleukin-6, interferon-γ, neopterin and sCD14), kynurenine and tryptophan concentrations. The influence of the number of HHV co-infection and K/T ratio on CD4 T-cell recovery was assessed using multivariate Poisson regression. RESULTS A total of 232 HIV-infected participants were recruited and all participants were seropositive for at least one HHV; 96.1% with CMV, 86.6% with VZV, 70.7% with HSV-1 and 53.9% with HSV-2. K/T ratio had a significant positive correlation with CMV (rho = 0.205, p = 0.002), VZV (rho = 0.173, p = 0.009) and a tendency with HSV-2 (rho = 0.120, p = 0.070), with CMV antibody titer demonstrating the strongest modulating effect on K/T ratio among the four HHVs assessed in SOM analysis. In multivariate analysis, higher K/T ratio (p = 0.03) and increasing number of HHV co-infections (p<0.001) were independently associated with poorer CD4 T-cell recovery following 12 months of ART initiation. CONCLUSION Multiple HHV co-infections are common among ART-treated HIV-infected participants in the developing country setting and associated with persistent immune activation and poorer CD4 T-cell recovery.
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Affiliation(s)
- Siew Hwei Yap
- Centre of Excellence for Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia
| | - Noor Kamila Abdullah
- Centre of Excellence for Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia
| | - Megan McStea
- Centre of Excellence for Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia
| | - Kozo Takayama
- Department of Pharmaceutics, Hoshi University, Tokyo, Japan
| | - Meng Li Chong
- Centre of Excellence for Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia
| | - Elisa Crisci
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Marie Larsson
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Iskandar Azwa
- Centre of Excellence for Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia
- Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Adeeba Kamarulzaman
- Centre of Excellence for Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia
- Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kok Hoong Leong
- Department of Pharmacy, University of Malaya, Kuala Lumpur, Malaysia
| | - Yin Ling Woo
- Centre of Excellence for Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia
- Department of Obstetrics & Gynecology, University of Malaya, Kuala Lumpur, Malaysia
| | - Reena Rajasuriar
- Centre of Excellence for Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia
- Department of Pharmacy, University of Malaya, Kuala Lumpur, Malaysia
- Peter Doherty Institute for Infection and Immunity, Melbourne University, Victoria, Australia
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Darraj M, Shafer LA, Chan S, Kasper K, Keynan Y. Rapid CD4 decline prior to antiretroviral therapy predicts subsequent failure to reconstitute despite HIV viral suppression. J Infect Public Health 2017; 11:265-269. [PMID: 28826735 DOI: 10.1016/j.jiph.2017.08.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 06/03/2017] [Accepted: 08/04/2017] [Indexed: 11/17/2022] Open
Abstract
HIV-1 infection is characterized by loss of CD4T cells, leading to immunodeficiency. Initiation of antiretroviral therapy (ART) results in suppression of the viral load and increased CD4 counts. Both viral and host factors determine CD4 cell responses to ART with approximately 15-30% of individuals having suboptimal increase of CD4T cell count, most commonly due to lack of compliance to ART. A smaller fraction of patients will have immune reconstitution failure and suboptimal CD4 increase despite suppression of HIV replication, and these individuals are at risk for adverse health outcomes. We sought to characterize the factors associated with decreased immunological response among Manitoba's HIV patient population. This retrospective case-control study included HIV patients with immune reconstitution failure despite suppression of HIV replication by ART. The immune reconstitution failure was defined by CD4 cell count increase from baseline of less than 100 CD4 cells/mm3 or lack of increase to above 200 CD4 cells/mm3 within one year of viral load suppression. Age and nadir CD4 cell counts are known risk factors associated with immune reconstitution failure. We chose controls (Patients with immune reconstitution success) of similar age and CD4 nadir cell with cases (Patients with immune reconstitution failure). We explored the potential effects of gender, HLA type, presence of co-infection, ethnicity, ART type, and rate of pre-treatment CD4 decline among cases and controls. Of more than 550 patients followed by our HIV clinic, 42 individuals met our definition of immune reconstitution failure and they were assigned to the cases group. 31 patients, comprising a range of ages and CD4 nadirs similar to those of the cases, were assigned to the control group. Our primary analysis was a regression model, predicting post-ART change in CD4 over time. After controlling for age and nadir CD4 cell counts, the only potential predictor that appears consistently associated with the rate of post-ART rise in CD4 over time in our cohort, regardless of the other variables that we have controlled for, is the rate of decline in CD4 pre-ART initiation. Several factors have been variably correlated with immune reconstitution failure of CD4 T cell count. Age and low CD4 nadir are factors previously shown to correlate with immune reconstitution failure; and we have controlled for them in our study. Another possible predictor is the rate of decline in CD4 pre-ART, which can serve as an additional marker of reconstitution failure and necessitate prioritizing individuals to ART initiation or identification of a subset of individuals that may be targeted for future adjunct strategies to improve immune recovery.
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Affiliation(s)
- Majid Darraj
- Department of Internal Medicine, Jazan University, Saudi Arabia; Manitoba HIV Program, Canada; Department of Internal Medicine, University of Manitoba, Canada
| | - Leigh A Shafer
- Department of Internal Medicine, University of Manitoba, Canada
| | | | - Ken Kasper
- Manitoba HIV Program, Canada; Department of Internal Medicine, University of Manitoba, Canada
| | - Yoav Keynan
- Manitoba HIV Program, Canada; Department of Internal Medicine, University of Manitoba, Canada; Department of Medical Microbiology, Department of Community Health Sciences, University of Manitoba, Canada.
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Affiliation(s)
- Katalin Andrea Wilkinson
- Clinical Infectious Diseases Research Initiative, University of Cape Town, 7925 Cape Town, South Africa; Department of Medicine, University of Cape Town, 7925 Cape Town, South Africa; Institute of Infectious Disease and Molecular Medicine, University of Cape Town, 7925 Cape Town, South Africa; The Francis Crick Institute, Mill Hill Laboratory, London NW7 1AA, United Kingdom
| | - Naomi Walker
- Clinical Infectious Diseases Research Initiative, University of Cape Town, 7925 Cape Town, South Africa; Institute of Infectious Disease and Molecular Medicine, University of Cape Town, 7925 Cape Town, South Africa; Department of Infectious Diseases and Immunity, Imperial College London, London W12 0NN, United Kingdom; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London WC1E 7HT, United Kingdom
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18
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Xia S, Li X, Shi Y, Liu J, Zhang M, Gu T, Pan S, Song L, Xu J, Sun Y, Zhao Q, Lu Z, Lu P, Li H. A Retrospective Cohort Study of Lesion Distribution of HIV-1 Infection Patients With Cryptococcal Meningoencephalitis on MRI: Correlation With Immunity and Immune Reconstitution. Medicine (Baltimore) 2016; 95:e2654. [PMID: 26871791 PMCID: PMC4753886 DOI: 10.1097/md.0000000000002654] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The objective of this paper is to correlate the MRI distribution of cryptococcal meningoencephalitis in HIV-1 infection patients with CD4 T cell count and immune reconstitution effect.A large retrospective cohort study of HIV patients from multi-HIV centers in China was studied to demonstrate the MRI distribution of cryptococcal meningoencephalitis and its correlation with the different immune status.The consecutive clinical and neuroimaging data of 55 HIV-1-infected patients with cryptococcal meningoencephalitis collected at multi-HIV centers in China during the years of 2011 to 2014 was retrospectively analyzed. The enrolled patients were divided into 2 groups based on the distribution of lesions. One group of patients had their lesions at the central brain (group 1, n = 34) and the other group of patients had their lesions at the superficial brain (group 2, n = 21). We explored their MRI characterization of brain. In addition, we also compared their CD4 T cell counts and immune reconstitution effects between the 2 groups based on the imaging findings.No statistical difference was found in terms of age and gender between the 2 groups. The medians of CD4 T cell counts were 11.67 cells/mm (3.00-52.00 cells/mm) in group 1 and 42.00 cells/mm (10.00-252.00 cells/mm) in group 2. Statistical difference of CD4 T cell count was found between the 2 groups (P = 0.023). Thirteen patients in group 1 (13/34) and 12 patients in group 2 (12/21) received highly active antiretroviral treatment (HAART). Patients of group 2 received HAART therapy more frequently than patients of group 1 (P = 0.021).Central and superficial brain lesions detected by MR imaging in HIV-1-infected patients with cryptococcal meningoencephalitis are in correlation with the host immunity and HAART therapy.
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Affiliation(s)
- Shuang Xia
- From the Department of Radiology, Tianjin First Central Hospital (SX, MZ, TG), Tianjin; Department of Radiology, Youan Hospital Affiliated of Capital Medical University (XL, HL), Xitoutiao, Youan Menwai, Beijing; Department of Radiology, Zhengzhou Sixth People's Hospital (YS, LS), Zhengzhou, Henan Province; Department of Radiology, Guangzhou Eighth People's Hospital (JL), Guangzhou, Guangdong Province; Department of Radiology, Shengjing Hospital of China Medical University (SP), Shenyang, Liaoning Province; Department of Infection, Zhengzhou Sixth People's Hospital (JX, YS, QZ), Zhengzhou, Henan Province; Department of Radiology, Zhongnan Hospital of Wuhan University (ZL), Wuhan, Hubei Province; and Department of Radiology, Shenzhen Third People's Hospital of Guangdong Medical College (PL), Shenzhen, Guangdong Province
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Zhang ZQ, Wang J, Hoy Z, Keegan A, Bhagwat S, Gigliotti F, Wright TW. Neither classical nor alternative macrophage activation is required for Pneumocystis clearance during immune reconstitution inflammatory syndrome. Infect Immun 2015; 83:4594-603. [PMID: 26371121 PMCID: PMC4645389 DOI: 10.1128/iai.00763-15] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 09/05/2015] [Indexed: 11/20/2022] Open
Abstract
Pneumocystis is a respiratory fungal pathogen that causes pneumonia (Pneumocystis pneumonia [PcP]) in immunocompromised patients. Alveolar macrophages are critical effectors for CD4(+) T cell-dependent clearance of Pneumocystis, and previous studies found that alternative macrophage activation accelerates fungal clearance during PcP-related immune reconstitution inflammatory syndrome (IRIS). However, the requirement for either classically or alternatively activated macrophages for Pneumocystis clearance has not been determined. Therefore, RAG2(-/-) mice lacking either the interferon gamma (IFN-γ) receptor (IFN-γR) or interleukin 4 receptor alpha (IL-4Rα) were infected with Pneumocystis. These mice were then immune reconstituted with wild-type lymphocytes to preserve the normal T helper response while preventing downstream effects of Th1 or Th2 effector cytokines on macrophage polarization. As expected, RAG2(-/-) mice developed severe disease but effectively cleared Pneumocystis and resolved IRIS. Neither RAG/IFN-γR(-/-) nor RAG/IL-4Rα(-/-) mice displayed impaired Pneumocystis clearance. However, RAG/IFN-γR(-/-) mice developed a dysregulated immune response, with exacerbated IRIS and greater pulmonary function deficits than those in RAG2 and RAG/IL-4Rα(-/-) mice. RAG/IFN-γR(-/-) mice had elevated numbers of lung CD4(+) T cells, neutrophils, eosinophils, and NK cells but severely depressed numbers of lung CD8(+) T suppressor cells. Impaired lung CD8(+) T cell responses in RAG/IFN-γR(-/-) mice were associated with elevated lung IFN-γ levels, and neutralization of IFN-γ restored the CD8 response. These data demonstrate that restricting the ability of macrophages to polarize in response to Th1 or Th2 cytokines does not impair Pneumocystis clearance. However, a cell type-specific IFN-γ/IFN-γR-dependent mechanism regulates CD8(+) T suppressor cell recruitment, limits immunopathogenesis, preserves lung function, and enhances the resolution of PcP-related IRIS.
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MESH Headings
- Animals
- CD8-Positive T-Lymphocytes/immunology
- CD8-Positive T-Lymphocytes/microbiology
- CD8-Positive T-Lymphocytes/pathology
- DNA-Binding Proteins/deficiency
- DNA-Binding Proteins/genetics
- DNA-Binding Proteins/immunology
- Eosinophils/immunology
- Eosinophils/microbiology
- Eosinophils/pathology
- Gene Expression Regulation
- Host-Pathogen Interactions
- Immune Reconstitution Inflammatory Syndrome/genetics
- Immune Reconstitution Inflammatory Syndrome/immunology
- Immune Reconstitution Inflammatory Syndrome/microbiology
- Immune Reconstitution Inflammatory Syndrome/pathology
- Killer Cells, Natural/immunology
- Killer Cells, Natural/microbiology
- Killer Cells, Natural/pathology
- Lung/immunology
- Lung/microbiology
- Lung/pathology
- Macrophage Activation
- Macrophages, Alveolar/immunology
- Macrophages, Alveolar/microbiology
- Macrophages, Alveolar/pathology
- Mice
- Mice, Knockout
- Mice, SCID
- Neutrophils/immunology
- Neutrophils/microbiology
- Neutrophils/pathology
- Pneumocystis/immunology
- Pneumocystis/pathogenicity
- Pneumonia, Pneumocystis/genetics
- Pneumonia, Pneumocystis/immunology
- Pneumonia, Pneumocystis/microbiology
- Pneumonia, Pneumocystis/pathology
- Receptors, Cell Surface/deficiency
- Receptors, Cell Surface/genetics
- Receptors, Cell Surface/immunology
- Receptors, Interferon/deficiency
- Receptors, Interferon/genetics
- Receptors, Interferon/immunology
- Signal Transduction
- T-Lymphocytes, Helper-Inducer/immunology
- T-Lymphocytes, Helper-Inducer/microbiology
- T-Lymphocytes, Helper-Inducer/pathology
- Th1-Th2 Balance
- Interferon gamma Receptor
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Affiliation(s)
- Zhuo-Qian Zhang
- Department of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Jing Wang
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Zachary Hoy
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Achsah Keegan
- Center for Vascular and Inflammatory Diseases, Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Samir Bhagwat
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Francis Gigliotti
- Department of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Terry W Wright
- Department of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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20
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Abstract
Recovery from severe immunosuppression requires hematopoietic stem cell reconstitution and effective thymopoiesis to restore a functional immune cell repertoire. Herein, a model of immune cell reconstitution consequent to potentially lethal doses of irradiation is described, which may be valuable in evaluating potential medical countermeasures. Male rhesus macaques were total body irradiated by exposure to 6.00 Gy 250 kVp x-radiation (midline tissue dose, 0.13 Gy min), resulting in an approximate LD10/60 (n = 5/59). Animals received medical management, and hematopoietic and immune cell recovery was assessed (n ≤ 14) through 370 d post exposure. A subset of animals (n ≤ 8) was examined through 700 d. Myeloid recovery was assessed by neutrophil and platelet-related parameters. Lymphoid recovery was assessed by the absolute lymphocyte count and FACS-based phenotyping of B- and T-cell subsets. Recent thymic emigrants were identified by T cell receptor excision circle quantification. Severe neutropenia, lymphopenia, and thrombocytopenia resolved within 30 d. Total CD3+ cells μL required 60 d to reach values 60% of normal, followed by subsequent slow recovery to approximately normal by 180 d post irradiation. Recovery of CD3+4+ and CD3+8+ cell memory and naïve subsets were markedly different. Memory populations were ≥ 100% of normal by day 60, whereas naïve populations were only 57% normal at 180 d and never fully recovered to baseline post irradiation. Total (CD20+) B cells μL were within normal levels by 77 d post exposure. This animal model elucidates the variable T- and B-cell subset recovery kinetics after a potentially lethal dose of total-body irradiation that are dependent on marrow-derived stem and progenitor cell recovery, peripheral homeostatic expansion, and thymopoiesis.
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Affiliation(s)
- Ann M. Farese
- University of Maryland, School of Medicine, Dept. of Radiation Oncology, Baltimore, MD
| | - Kim G. Hankey
- University of Maryland, School of Medicine, Dept. of Radiation Oncology, Baltimore, MD
| | | | - Thomas J. MacVittie
- University of Maryland, School of Medicine, Dept. of Radiation Oncology, Baltimore, MD
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21
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Gupta M, Jafri K, Sharim R, Silverman S, Sindher SB, Shahane A, Kwan M. Immune reconstitution inflammatory syndrome associated with biologic therapy. Curr Allergy Asthma Rep 2015; 15:499. [PMID: 25504263 DOI: 10.1007/s11882-014-0499-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The use of biologics in the treatment of autoimmune disease, cancer, and other immune conditions has revolutionized medical care in these areas. However, there are drawbacks to the use of these medications including increased susceptibility to opportunistic infections. One unforeseen risk once opportunistic infection has occurred with biologic use is the onset of immune reconstitution inflammatory syndrome (IRIS) upon drug withdrawal. Although originally described in human immunodeficiency virus (HIV) patients receiving highly active antiretroviral therapy, it has become clear that IRIS may occur when recovery of immune function follows opportunistic infection in the setting of previous immune compromise/suppression. In this review, we draw attention to this potential pitfall on the use of biologic drugs.
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Affiliation(s)
- Malika Gupta
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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22
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Jarvis JN, Meintjes G, Bicanic T, Buffa V, Hogan L, Mo S, Tomlinson G, Kropf P, Noursadeghi M, Harrison TS. Cerebrospinal fluid cytokine profiles predict risk of early mortality and immune reconstitution inflammatory syndrome in HIV-associated cryptococcal meningitis. PLoS Pathog 2015; 11:e1004754. [PMID: 25853653 PMCID: PMC4390200 DOI: 10.1371/journal.ppat.1004754] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Accepted: 02/19/2015] [Indexed: 11/18/2022] Open
Abstract
Understanding the host immune response during cryptococcal meningitis (CM) is of critical importance for the development of immunomodulatory therapies. We profiled the cerebrospinal fluid (CSF) immune-response in ninety patients with HIV-associated CM, and examined associations between immune phenotype and clinical outcome. CSF cytokine, chemokine, and macrophage activation marker concentrations were assayed at disease presentation, and associations between these parameters and microbiological and clinical outcomes were examined using principal component analysis (PCA). PCA demonstrated a co-correlated CSF cytokine and chemokine response consisting primarily of Th1, Th2, and Th17-type cytokines. The presence of this CSF cytokine response was associated with evidence of increased macrophage activation, more rapid clearance of Cryptococci from CSF, and survival at 2 weeks. The key components of this protective immune-response were interleukin (IL)-6 and interferon-γ, IL-4, IL-10 and IL-17 levels also made a modest positive contribution to the PC1 score. A second component of co-correlated chemokines was identified by PCA, consisting primarily of monocyte chemotactic protein-1 (MCP-1) and macrophage inflammatory protein-1α (MIP-1α). High CSF chemokine concentrations were associated with low peripheral CD4 cell counts and CSF lymphocyte counts and were predictive of immune reconstitution inflammatory syndrome (IRIS). In conclusion CSF cytokine and chemokine profiles predict risk of early mortality and IRIS in HIV-associated CM. We speculate that the presence of even minimal Cryptococcus-specific Th1-type CD4+ T-cell responses lead to increased recruitment of circulating lymphocytes and monocytes into the central nervous system (CNS), more effective activation of CNS macrophages and microglial cells, and faster organism clearance; while high CNS chemokine levels may predispose to over recruitment or inappropriate recruitment of immune cells to the CNS and IRIS following peripheral immune reconstitution with ART. These results provide a rational basis for future studies of immune modulation in CM, and demonstrate the potential of baseline immune profiling to identify CM patients most at risk of mortality and subsequent IRIS. Cryptococcal meningitis is a severe opportunistic infection, estimated to kill several hundred thousand HIV-infected individuals each year. One of the factors contributing to this high death toll is the inadequacy of antifungal treatments. As few novel antifungal drugs are being developed, several groups have started to investigate the potential of immune modulation, with treatments designed to change the patient’s immune response to infection. However, our understanding of the immune response to cryptococcal infection in HIV-infected patients, and how these responses impact on clinical outcomes, is limited. In this study, we took advantage of the fact that we can sample cerebrospinal fluid (CSF) from the site of the infection in patients when they develop cryptococcal meningitis. We undertook a detailed analysis measuring levels of immune response parameters in the CSF of these patients, and demonstrated that there were several distinct components of the immune response. Variations in these responses were associated with both the rate at which patients cleared their infection during treatment, and with mortality. Our results provide a basis for the development of future immunomodulatory therapies, and may allow identification of patients most at risk of dying, enabling more intensive treatments to be given to those at highest risk.
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Affiliation(s)
- Joseph N. Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Botswana-UPenn Partnership, Gaborone, Botswana
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
- * E-mail:
| | - Graeme Meintjes
- Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, South Africa
- Department of Medicine, Imperial College London, London, United Kingdom
| | - Tihana Bicanic
- Research Centre for Infection and Immunity, Division of Clinical Sciences, St. George’s University of London, London, United Kingdom
| | - Viviana Buffa
- Research Centre for Infection and Immunity, Division of Clinical Sciences, St. George’s University of London, London, United Kingdom
| | - Louise Hogan
- Research Centre for Infection and Immunity, Division of Clinical Sciences, St. George’s University of London, London, United Kingdom
| | - Stephanie Mo
- Department of Medicine, Imperial College London, London, United Kingdom
| | - Gillian Tomlinson
- Division of Infection and Immunity, University College London, London, United Kingdom
| | - Pascale Kropf
- Department of Medicine, Imperial College London, London, United Kingdom
| | - Mahdad Noursadeghi
- Division of Infection and Immunity, University College London, London, United Kingdom
| | - Thomas S. Harrison
- Research Centre for Infection and Immunity, Division of Clinical Sciences, St. George’s University of London, London, United Kingdom
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23
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Hatsuse M, Fuchida SI, Okano A, Murakami S, Shimazaki C. [Secondary MGUS following by adenovirus-induced hemorrhagic cystitis after autologous peripheral blood stem cell transplantation in a patient with multiple myeloma]. Rinsho Ketsueki 2014; 55:2277-2282. [PMID: 25501407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
A 61-year-old man with multiple myeloma (IgG-κ) received autologous peripheral blood stem cell transplantation (PBSCT) after induction of VAD in July 2009, and obtained a very good partial response. In November 2009, he was admitted to our hospital because of adenovirus-induced hemorrhagic cystitis and pneumocystis jiroveci pneumonia. The pneumonia resolved with sulfamethoxazole and steroid pulse therapy, and cystitis subsided spontaneously. In December 2009, serum protein electrophoresis showed two abnormal protein bands (APB)(IgG-λ, IgA-λ), different from the original M-protein, and IgG thereafter increased to 2,771 mg/dl with a concomitant increase in anti-adenovirus antibody to 4,096. In October 2010, APB disappeared. To date, he has been in stable complete remission for five years since PBSCT. The emergence of APB is considered to be a surrogate marker for long-term remission. Immune reconstitution syndrome and APB after high dose chemotherapy following PBSCT are discussed herein.
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Affiliation(s)
- Mayumi Hatsuse
- Department of Hematology, Japan Community Health Care Organization, Kyoto Kuramaguchi Medical Center
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24
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Badaró R, Gonçalves LO, Gois LL, Maia ZPG, Benson C, Grassi MFR. Leishmaniasis as a Manifestation of Immune Reconstitution Inflammatory Syndrome (IRIS) in HIV-Infected Patients: A Literature Review. J Int Assoc Provid AIDS Care 2014; 14:402-7. [PMID: 25331225 DOI: 10.1177/2325957414555225] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION After the onset of highly active antiretroviral therapy (HAART), some HIV-infected patients present a severe inflammation in response to a latent or a previously treated opportunistic pathogen termed immune reconstitution inflammatory syndrome (IRIS). Few reports of tegumentary and visceral leishmaniasis have been described in association with IRIS. METHODS A systematic literature review of IRIS in association with leishmaniasis identified 34 reported cases. RESULTS AND DISCUSSION The majority of these occurred in males 4 months following the onset of HAART. The mean CD4 count before HAART was 94 ± 77 cells/mm³ increasing to 5 times the initial value between the onset of HAART and IRIS presentation. Visceral leishmaniasis and post-kala-azar dermal leishmaniasis were the most commonly reported clinical manifestations, followed by tegumentary leishmaniasis and uveitis. CONCLUSIONS Commonly found characteristics included cutaneous involvement, regardless of Leishmania species; appearance of lesions unrelated to time of probable Leishmania infection; rapid recovery of CD4 count following HAART; and rapid progression.
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Affiliation(s)
- Roberto Badaró
- Universidade Federal da Bahia, Complexo Hospitalar Prof Edgard Santos, Unidade docente de Infectologia, Salvador, BA, Brazil
| | - Larissa O Gonçalves
- Universidade Federal da Bahia, Complexo Hospitalar Prof Edgard Santos, Unidade docente de Infectologia, Salvador, BA, Brazil
| | - Luana L Gois
- Fundação Oswaldo Cruz, Centro de Pesquisa Gonçalo Moniz, Laboratório Avançado de Saúde Pública, Salvador, BA, Brazil Escola Bahiana de Medicina e Saúde Pública, Faculdade de Medicina, Salvador, BA, Brazil
| | - Zuinara Pereira Gusmão Maia
- Universidade Federal da Bahia, Complexo Hospitalar Prof Edgard Santos, Unidade docente de Infectologia, Salvador, BA, Brazil
| | - Constance Benson
- University of California San Diego, Division of Infectious Diseases, La Jolla, CA, USA
| | - Maria Fernanda Rios Grassi
- Fundação Oswaldo Cruz, Centro de Pesquisa Gonçalo Moniz, Laboratório Avançado de Saúde Pública, Salvador, BA, Brazil Escola Bahiana de Medicina e Saúde Pública, Faculdade de Medicina, Salvador, BA, Brazil
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25
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Andrade BB, Singh A, Narendran G, Schechter ME, Nayak K, Subramanian S, Anbalagan S, Jensen SMR, Porter BO, Antonelli LR, Wilkinson KA, Wilkinson RJ, Meintjes G, van der Plas H, Follmann D, Barber DL, Swaminathan S, Sher A, Sereti I. Mycobacterial antigen driven activation of CD14++CD16- monocytes is a predictor of tuberculosis-associated immune reconstitution inflammatory syndrome. PLoS Pathog 2014; 10:e1004433. [PMID: 25275318 PMCID: PMC4183698 DOI: 10.1371/journal.ppat.1004433] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 08/29/2014] [Indexed: 01/07/2023] Open
Abstract
Paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is an aberrant inflammatory response occurring in a subset of TB-HIV co-infected patients initiating anti-retroviral therapy (ART). Here, we examined monocyte activation by prospectively quantitating pro-inflammatory plasma markers and monocyte subsets in TB-HIV co-infected patients from a South Indian cohort at baseline and following ART initiation at the time of IRIS, or at equivalent time points in non-IRIS controls. Pro-inflammatory biomarkers of innate and myeloid cell activation were increased in plasma of IRIS patients pre-ART and at the time of IRIS; this association was confirmed in a second cohort in South Africa. Increased expression of these markers correlated with elevated antigen load as measured by higher sputum culture grade and shorter duration of anti-TB therapy. Phenotypic analysis revealed the frequency of CD14++CD16− monocytes was an independent predictor of TB-IRIS, and was closely associated with plasma levels of CRP, TNF, IL-6 and tissue factor during IRIS. In addition, production of inflammatory cytokines by monocytes was higher in IRIS patients compared to controls pre-ART. These data point to a major role of mycobacterial antigen load and myeloid cell hyperactivation in the pathogenesis of TB-IRIS, and implicate monocytes and monocyte-derived cytokines as potential targets for TB-IRIS prevention or treatment. Tuberculosis and HIV majorly impact host immune responses, resulting in immune deregulation and inflammation-driven tissue damage. Initiation of anti-retroviral therapy in patients with HIV-TB co-infection may result in immune reconstitution inflammatory syndrome (TB-IRIS), a disorder associated with increased immunopathology due to unfettered inflammation after CD4+ T-cell reconstitution. Monocytes are critical to the innate immune system and play an important role in several inflammatory conditions associated with chronic infections. Immunopathogenesis of TB-IRIS has been linked to activation of the adaptive immune response against opportunistic infection, yet the role of monocytes is still unknown. Here we investigated associations between soluble markers of monocyte activation, differential activation of monocyte subsets and TB-IRIS prospectively in two geographically distinct HIV-TB co-infected patient cohorts. Prior to ART initiation, patients who developed IRIS displayed a biosignature of elevated soluble monocyte activation markers, which were closely related to the mycobacterial antigen load in sputum samples. Amongst monocyte subsets, we observed that pre-ART circulating CD14++CD16− cell frequency independently predicted TB-IRIS and expanded during IRIS events. This monocyte subset was tightly associated with systemic markers of inflammation, and was found to produce inflammatory cytokines. Identification of this monocyte subset and its link with inflammation may lead to conception of novel therapies reducing immunopathology in TB-IRIS.
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Affiliation(s)
- Bruno B. Andrade
- Immunobiology Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
- * E-mail: (BBA); (IS)
| | - Amrit Singh
- Clinical and Molecular Retrovirology Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | | | - Melissa E. Schechter
- Clinical and Molecular Retrovirology Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Kaustuv Nayak
- National Institute for Research in Tuberculosis, Chennai, India
| | | | | | - Stig M. R. Jensen
- Clinical and Molecular Retrovirology Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Brian O. Porter
- Clinical and Molecular Retrovirology Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Lis R. Antonelli
- Laboratório de Imunopatologia, Centro de Pesquisas René Rachou, Fundação Oswaldo Cruz, Belo Horizonte, Minas Gerais, Brazil
| | - Katalin A. Wilkinson
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Robert J. Wilkinson
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, Imperial College London, London, United Kingdom
- MRC National Institute for Medical Research, London, United Kingdom
| | - Graeme Meintjes
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, Imperial College London, London, United Kingdom
| | - Helen van der Plas
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Dean Follmann
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Daniel L. Barber
- T-Lymphocyte Biology Unit, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | | | - Alan Sher
- Immunobiology Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Irini Sereti
- Clinical and Molecular Retrovirology Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
- * E-mail: (BBA); (IS)
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26
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López Aventín D, Martín-Ezquerra G, Villar García J, Pujol RM. Immune reconstitution-associated cutaneous sarcoid-like eruption in a patient with previous disseminated cutaneous leishmaniasis: a diagnostic challenge. J Dermatol 2014; 41:648-9. [PMID: 24930785 DOI: 10.1111/1346-8138.12527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Daniel López Aventín
- Department of Dermatology, Hospital del Mar - Parc de Salut Mar, Barcelona, Spain
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27
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Fantauzzi A, Digiulio MA, Cavallari EN, d'Ettorre G, Vullo V, Mezzaroma I. Guillain Barre syndrome in an HIV-1-infected patient after the beginning of combined antiretroviral therapy: an immune reconstitution inflammatory syndrome? New Microbiol 2014; 37:103-107. [PMID: 24531178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 11/26/2013] [Indexed: 06/03/2023]
Abstract
HIV-1-associated Guillan-Barre syndrome (hGBS) is an ascendant progressive polyradiculoneuropathy described throughout the course of the viral disease, mainly associated with the acute retroviral syndrome. HGBS is occasionally described in severely immunocompromised subjects in the context of the immune reconstitution inflammatory syndrome. The case described occurred soon after the start of a combined antiretroviral treatment in an HIV-1 infected patient with ulcerative colitis in the absence of severe immunosuppression. This manifestation may be interpreted as an uncommon appearance of an immune reconstitution syndrome in the presence of a predisposing autoimmune pathology.
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Mitsumoto F, Murata M, Kato Y, Ura K, Takayama K, Hiramine S, Ikezaki H, Shimizu M, Toyoda K, Ogawa E, Aishima S, Furusyo N, Hayashi J. Hepatitis B virus-related immune reconstitution inflammatory syndrome in two patients coinfected with human immunodeficiency virus diagnosed with a liver biopsy. Intern Med 2014; 53:2165-70. [PMID: 25224208 DOI: 10.2169/internalmedicine.53.2503] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Hepatic flares occurred in two patients with HBV/HIV coinfection following the commencement of antiretroviral therapy (ART). At that time, the HIV RNA and HBV DNA levels had decreased. The results of liver biopsies showed lymphocytic infiltration that was diffusely positive for CD8(+) T cells in the portal areas and lobules. These findings suggested HBV-related immune reconstitution inflammatory syndrome (IRIS). The alanine aminotransferase levels of both patients gradually decreased with the continuation of ART. Because there are few reports of the liver histology of HBV-related IRIS, these cases provide a better understanding of the pathogenesis of HBV-related IRIS.
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Affiliation(s)
- Fujiko Mitsumoto
- Department of General Internal Medicine, Kyushu University Hospital, Japan
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29
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Abstract
BACKGROUND The use of hematopoietic stem cell transplantations (HSCTs) as a curative therapy for life-threatening immunodeficiencies has had a profound impact on clinical outcomes. A subset of patients may experience immune reconstitution inflammatory syndrome (IRIS) post-transplant affecting the thyroid gland, but this has received little attention in the pediatric literature. We present the clinical, biochemical, and cytological course of patients with Graves' disease after HSCT in the pediatric population. PATIENTS AND METHODS Four children (median age 1.5 years, range 2 months-9 years) underwent HSCT. The conditioning regimen included chemotherapy but not radiotherapy. None of the children or their donors had evidence of thyroid disease pre-HSCT or during the follow-up period. Engraftment was uneventful in all, with stable donor T-cell chimerism, and none had evidence of graft-versus-host disease. RESULTS Patients developed Graves' disease soon after undergoing HSCT, with a median time interval between HSCT and Graves' disease of 22 months (range 16-28 months). Graves' disease was diagnosed on the basis of clinical and biochemical parameters, including a suppressed thyrotropin, raised free thyroxine, and raised thyrotropin receptor antibodies. Three patients were hypothyroid initially (suggestive of a Th1 profile) before Graves' disease (suggestive of a Th2 profile). In three patients, the clinical picture changed rapidly with hypothyroidism abruptly followed by profound thyroid hormone excess. The onset of Graves' IRIS coincided with a rapid expansion in naïve and total CD4. CONCLUSIONS Immunological dysregulation during T-cell engraftment is the most likely mechanism for developing Graves' IRIS after allogenic HSTC. Clinicians need to be aware that HSCT-engendered immune recovery may result in a particularly aggressive form of autoimmune thyroid disease in children with implications for the developing central nervous system. Careful surveillance of thyroid function post-HSCT is essential.
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Affiliation(s)
- Akash Sinha
- Department of Pediatric Endocrinology, Great North Children's Hospital, Newcastle upon Tyne, UK
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Chang CC, Omarjee S, Lim A, Spelman T, Gosnell BI, Carr WH, Elliott JH, Moosa MYS, Ndung'u T, French MA, Lewin SR. Chemokine levels and chemokine receptor expression in the blood and the cerebrospinal fluid of HIV-infected patients with cryptococcal meningitis and cryptococcosis-associated immune reconstitution inflammatory syndrome. J Infect Dis 2013; 208:1604-12. [PMID: 23908492 DOI: 10.1093/infdis/jit388] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Human immunodeficiency virus-infected patients with treated cryptococcal meningitis who start combination antiretroviral therapy (cART) are at risk of further neurological deterioration, in part caused by paradoxical cryptococcosis-associated immune reconstitution inflammatory syndrome (C-IRIS). We hypothesized that C-IRIS is associated with alterations of chemokine receptor expression on T cells and chemokine concentrations in cerebrospinal fluid (CSF) that enhance recruitment of T-helper 1 cells and/or myeloid cells to the central nervous system. METHODS In a prospective study of 128 human immunodeficiency virus-infected patients with cryptococcal meningitis who received antifungal therapy followed by cART, we examined the proportions of CD4(+) and CD8(+) T cells expressing CCR5 and/or CXCR3, in CSF and whole blood and the concentrations of CXCL10, CCL2, and CCL3 in stored CSF and plasma. RESULTS The proportion of CD4(+) and CD8(+) T cells expressing CXCR3(+)CCR5(+) and the concentrations of CXCL10, CCL2 and CCL3 were increased in CSF compared with blood at cART initiation (P < .0001). Patients with C-IRIS (n = 26), compared with those with no neurological deterioration (n = 63), had higher CSF ratios of CCL2/CXCL10 and CCL3/CXCL10 and higher proportions of CXCR3(+)CCR5(+)CD8(+)T cells in CSF compared with blood at cART initiation (P = .03, .0053, and .02, respectively). CONCLUSION CD8(+) T-cell and myeloid cell trafficking to the central nervous system may predispose patients to C-IRIS.
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Tran HTT, Van den Bergh R, Vu TN, Laukens K, Worodria W, Loembé MM, Colebunders R, Kestens L, De Baetselier P, Raes G. The role of monocytes in the development of Tuberculosis-associated Immune Reconstitution Inflammatory Syndrome. Immunobiology 2013; 219:37-44. [PMID: 23958034 DOI: 10.1016/j.imbio.2013.07.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 07/02/2013] [Accepted: 07/05/2013] [Indexed: 01/29/2023]
Abstract
BACKGROUND Tuberculosis-associated Immune Reconstitution Inflammatory Syndrome (TB-IRIS) is a common complication of combined antiretroviral therapy (cART) in HIV-TB co-infected patients. However, the disease mechanism is poorly understood, prognosis of TB-IRIS is currently impossible, and diagnosis is highly challenging. We analyzed whether the gene expression of monocytes could be correlated with TB-IRIS pathogenesis and could be used to classify patients predisposed to TB-IRIS. METHODS Monocyte gene expression was compared between patients who developed TB-IRIS and matched controls. We carried out whole-genome expression profiling using Affymetrix GeneChip(®) ST 1.1 arrays at two time-points: before cART initiation (baseline) and at week two post-cART initiation. For each time-point, we used different statistical approaches to identify molecular signatures which could be used as classifiers. We also functionally mapped the modulated cellular pathways using the software package Ingenuity Pathway Analysis. RESULTS At baseline, before introduction of cART and before onset of symptoms, monocyte gene expression was already perturbed in patients who subsequently developed TB-IRIS, indicating a possible involvement of monocytes in TB-IRIS predisposition. The differences in monocyte gene expression in TB-IRIS patients became even more clear after two weeks of cART (when TB-IRIS commonly occurs), with more than 100 genes for which expression showed a fold change greater than 1.5. Both at baseline and at week two post-cART initiation, a classifier of 8 and 9 genes, respectively could be built, which allowed discrimination of TB-IRIS cases and controls. Pathway analyses revealed that the majority of the dysregulated genes in TB-IRIS - at the time of the IRIS episode, but also already at baseline - are associated with infection and inflammation. Relevant biological functions which were perturbed before/during TB-IRIS included "Role of Pattern Recognition Receptors in Recognition of Bacteria and Viruses" and "Complement System". CONCLUSION Our results indicate an involvement of monocytes in predisposition to/development of TB-IRIS, and suggest a number of functional pathways which may play a role in TB-IRIS development. This comprehensive study of gene regulation in monocytes provides baseline data for further studies into biomarkers for prognosis and diagnosis of TB-IRIS.
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Affiliation(s)
- Huyen Thi Thanh Tran
- Cellular and Molecular Immunology Unit, Vrije Universiteit Brussel, Brussels, Belgium; Myeloid Cell Immunology Laboratory, VIB, Brussels, Belgium
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Tadokera R, Wilkinson KA, Meintjes GA, Skolimowska KH, Matthews K, Seldon R, Rangaka MX, Maartens G, Wilkinson RJ. Role of the interleukin 10 family of cytokines in patients with immune reconstitution inflammatory syndrome associated with HIV infection and tuberculosis. J Infect Dis 2013; 207:1148-56. [PMID: 23303806 PMCID: PMC3583273 DOI: 10.1093/infdis/jit002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2012] [Accepted: 10/30/2012] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The interleukin 10 (IL-10) family comprises cytokines structurally related to IL-10 that share signaling receptors that have conserved signaling cascades. The immunopathogenesis of immune reconstitution inflammatory syndrome (IRIS) in patients with human immunodeficiency virus (HIV) infection and tuberculosis remains incompletely understood. We hypothesized that a deficiency of IL-10 and its homologs may contribute to the immunopathology of IRIS in these patients. METHODS We performed a case-control analysis involving patients with HIV infection and tuberculosis who had IRIS at clinical presentation (tuberculosis-IRIS) and similar patients with HIV infection and tuberculosis who did not develop tuberculosis-IRIS (non-IRIS). Peripheral blood mononuclear cells (PBMCs) were cultured in the presence or absence of heat-killed Mycobacterium tuberculosis for 6 and 24 hours. Messenger RNA was analyzed by quantitative reverse transcription polymerase chain reaction analysis. Cytokine concentrations in serum were also determined. RESULTS Cultures of PBMCs stimulated with M. tuberculosis for 24 hours yielded higher IL-10 and interleukin 22 (IL-22) transcript levels for tuberculosis-IRIS patients, compared with non-IRIS patients. Analysis of corresponding serum samples showed significantly higher concentrations of IL-10 and IL-22 in tuberculosis-IRIS patients, compared with non-IRIS patients. CONCLUSIONS IL-10 and IL-22 were differentially induced in PBMCs from tuberculosis-IRIS patients after in vitro stimulation, and higher concentrations of their corresponding proteins were detected in serum (in vivo). The higher levels of IL-10 observed in this study may represent a compensatory antiinflammatory response during tuberculosis-IRIS. The elevated levels of IL-22 suggest an association between this cytokine and immunopathology during tuberculosis-IRIS.
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Affiliation(s)
- Rebecca Tadokera
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine
| | - Katalin A. Wilkinson
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine
- MRC National Institute for Medical Research, London, United Kingdom
| | - Graeme A. Meintjes
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine
- Department of Medicine, University of Cape Town, Cape Town
- Infectious Diseases Unit, G. F. Jooste Hospital, Manenberg, South Africa
- Department of Medicine, Imperial College London
| | - Keira H. Skolimowska
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine
| | - Kerryn Matthews
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine
| | - Ronnett Seldon
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine
| | - Molebogeng X. Rangaka
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine
| | - Gary Maartens
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine
- Division of Clinical Pharmacology
- Department of Medicine, University of Cape Town, Cape Town
- Infectious Diseases Unit, G. F. Jooste Hospital, Manenberg, South Africa
| | - Robert J. Wilkinson
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine
- Department of Medicine, University of Cape Town, Cape Town
- Infectious Diseases Unit, G. F. Jooste Hospital, Manenberg, South Africa
- Department of Medicine, Imperial College London
- MRC National Institute for Medical Research, London, United Kingdom
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Curran A, Falcó V, Pahissa A, Ribera E. Management of tuberculosis in HIV-infected patients. AIDS Rev 2012; 14:231-246. [PMID: 23258298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
HIV-tuberculosis coinfection is currently one of the greatest health threats, affecting millions of people worldwide, with high morbidity and mortality. Treating both infections can be a challenge and requires some expertise due to multidirectional drug interactions, risk of overlapping side effects, high pill burden and risk of immune reconstitution inflammatory syndrome. This article reviews the general management of tuberculosis/HIV coinfection, focusing on the optimal time to start antiretroviral therapy and which treatments can be safely used. The randomized clinical trials designed to answer the question of when to start antiretroviral therapy (SAPIT, CAMELIA, STRIDE and TIME), published in the last two years, are described and discussed in detail. Summarizing these trials' conclusions, antiretroviral therapy should be started within two weeks of starting tuberculosis treatment if the patient has less than 50 CD4/mm3 and wait to the end of the induction phase (8-12 weeks after starting tuberculosis treatment) if higher CD4 cell counts exist. Treatment options for both tuberculosis and HIV, including the newer available drugs and those in clinical trials, are revised and recommendations for dose adjustments are made based on the latest available literature, with special attention to drug-drug interactions and the necessity of dose adjustments with some drug combinations.
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Affiliation(s)
- Adrian Curran
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
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Price P, Haddow LJ, Affandi J, Agarwal U, Easterbrook PJ, Elliott J, French M, Kumar M, Moosa MYS, Oliver B, Singh S, Sola M, Saphonn V, Vun MC. Short communication: Plasma levels of vitamin D in HIV patients initiating antiretroviral therapy do not predict immune restoration disease associated with Mycobacterium tuberculosis. AIDS Res Hum Retroviruses 2012; 28:1216-9. [PMID: 22280097 DOI: 10.1089/aid.2011.0272] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Immune restoration disease associated with Mycobacterium tuberculosis (TB IRD) is clinically important among HIV patients commencing antiretroviral therapy in countries where tuberculosis is endemic. Vitamin D affects dendritic cell and T cell function and the antimicrobial activity of monocytes. Plasma levels of vitamin D and polymorphisms in the vitamin D receptor may affect tuberculosis, and HIV infection associates with vitamin D deficiency. Here we assess whether plasma vitamin D levels may predict TB IRD. Samples were available from prospective studies of TB IRD in Cambodia (26 cases), India (19 cases), and South Africa (29 cases). IRD cases and controls from each site were similar in age and baseline CD4(+) T cell count. Plasma samples were assessed using 25(OH) vitamin D immunoassay plates. DNA samples were available from a subset of patients and were genotyped for the VDR FokI (F/f) [C/T, rs10735810] SNP. When data from each cohort were pooled to assess ethnic/geographic differences, 25(OH)D levels were higher in Cambodian than Indian or South African patients (p<0.0001) and higher in South African than Indian patients (p<0.0001). TB IRD was not associated with differences in levels of 25(OH)D in any cohort (p=0.36-0.82), irrespective of the patients' prior TB diagnoses/treatment. Carriage of the minor allele of VDR FokI (F/f) was marginally associated with TB IRD in Indian patients (p=0.06) with no association in Cambodians. Neither plasma levels of vitamin D nor the vitamin D allele will usefully predict TB IRD in diverse populations from TB endemic regions.
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Affiliation(s)
- Patricia Price
- School of Pathology and Laboratory Medicine, University of Western Australia, Nedlands, Australia.
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Munawwar A, Singh S. AIDS associated tuberculosis: a catastrophic collision to evade the host immune system. Tuberculosis (Edinb) 2012; 92:384-7. [PMID: 22795795 DOI: 10.1016/j.tube.2012.05.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Revised: 03/04/2012] [Accepted: 05/11/2012] [Indexed: 02/07/2023]
Abstract
Human immunodeficiency virus (HIV) is a causative agent of AIDS while Mycobacterium tuberculosis causes human tuberculosis, independently. HIV and M. tuberculosis co-infection is an intriguing immunopathological phenomenon. The effect is not simply an additive but far more than that. This review gives an account of how various host and pathogen specific factors interplay to make this co-infection one of the worst co-infection, rightly named as medical "double jeopardy". We have attempted to recount some of the immune mechanisms how both these pathogens disturb the balance of host immune system resulting into defects in the host phagocytic response, leading to apoptosis and chemokine dysregulation. The HIV provides protected shelter to the M. tuberculosis and M. tuberculosis provides conducive atmosphere through the interplay of various chemokines. We also touch upon the treatment associated complications like Immune reconstitution inflammatory syndrome (IRIS) these patients face.
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Affiliation(s)
- Arshi Munawwar
- Division of Clinical Microbiology, All India Institute of Medical Sciences, New Delhi 110029, India
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Quiroga MF, Angerami MT, Santucci N, Ameri D, Francos JL, Wallach J, Sued O, Cahn P, Salomón H, Bottasso O. Dynamics of adrenal steroids are related to variations in Th1 and Treg populations during Mycobacterium tuberculosis infection in HIV positive persons. PLoS One 2012; 7:e33061. [PMID: 22431997 PMCID: PMC3303789 DOI: 10.1371/journal.pone.0033061] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Accepted: 02/03/2012] [Indexed: 12/11/2022] Open
Abstract
Tuberculosis (TB) remains the most frequent cause of illness and death from an infectious agent, and its interaction with HIV has devastating effects. We determined plasma levels of dehydroepiandrosterone (DHEA), its circulating form DHEA-suphate (DHEA-s) and cortisol in different stages of M. tuberculosis infection, and explored their role on the Th1 and Treg populations during different scenarios of HIV-TB coinfection, including the immune reconstitution inflammatory syndrome (IRIS), a condition related to antiretroviral treatment. DHEA levels were diminished in HIV-TB and HIV-TB IRIS patients compared to healthy donors (HD), HIV+ individuals and HIV+ individuals with latent TB (HIV-LTB), whereas dehydroepiandrosterone sulfate (DHEA-s) levels were markedly diminished in HIV-TB IRIS individuals. HIV-TB and IRIS patients presented a cortisol/DHEA ratio significantly higher than HIV+, HIV-LTB and HD individuals. A positive correlation was observed between DHEA-s and CD4 count among HIV-TB individuals. Conversely, cortisol plasma level inversely correlated with CD4 count within HIV-TB individuals. M. tuberculosis-specific Th1 lymphocyte count was increased after culturing PBMC from HIV-TB individuals in presence of DHEA. We observed an inverse correlation between DHEA-s plasma level and Treg frequency in co-infected individuals, and CD4+FoxP3+ Treg frequency was increased in HIV-TB and IRIS patients compared to other groups. Strikingly, we observed a prominent CD4+CD25-FoxP3+ population across HIV-TB and HIV-TB IRIS patients, which frequency correlated with DHEA plasma level. Finally, DHEA treatment negatively regulated FoxP3 expression without altering Treg frequency in co-infected patients. These data suggest an enhancing role for DHEA in the immune response against M. tuberculosis during HIV-TB coinfection and IRIS.
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Affiliation(s)
- Maria Florencia Quiroga
- Department of Microbiology, National Reference Center for AIDS, University of Buenos Aires School of Medicine, Buenos Aires, Argentina.
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Metz I, Radue EW, Oterino A, Kümpfel T, Wiendl H, Schippling S, Kuhle J, Sahraian MA, Gray F, Jakl V, Häusler D, Brück W. Pathology of immune reconstitution inflammatory syndrome in multiple sclerosis with natalizumab-associated progressive multifocal leukoencephalopathy. Acta Neuropathol 2012; 123:235-45. [PMID: 22057786 PMCID: PMC3259335 DOI: 10.1007/s00401-011-0900-5] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2011] [Revised: 10/16/2011] [Accepted: 10/24/2011] [Indexed: 11/01/2022]
Abstract
Natalizumab is an approved medication for highly active multiple sclerosis (MS). Progressive multifocal leukoencephalopathy (PML) may occur as a severe side effect of this drug. Here, we describe pathological and radiological characteristics of immune reconstitution inflammatory syndrome (IRIS), which occurs in natalizumab-associated PML after the cessation of therapy, and we differentiate it from ongoing PML. Brain biopsy tissue and MRI scans from five MS patients with natalizumab-associated PML were analyzed and their histology compared with non-MS PML. Histology showed an extensive CD8-dominated T cell infiltrate and numerous macrophages within lesions, and in nondemyelinated white and grey matter, in four out of five cases. Few or no virally infected cells were found. This was indicative of IRIS as known from HIV patients with PML. Outstandingly high numbers of plasma cells were present as compared to non-MS PML and typical MS lesions. MRI was compatible with IRIS, revealing enlarging lesions with a band-like or speckled contrast enhancement either at the lesion edge or within lesions. Only the fifth patient showed typical PML pathology, with low inflammation and high numbers of virally infected cells. This patient showed a similar interval between drug withdrawal and biopsy (3.5 months) to the rest of the cohort (range 2.5-4 months). MRI could not differentiate between PML-associated IRIS and ongoing PML. We describe in detail the histopathology of IRIS in natalizumab-associated PML. PML-IRIS, ongoing PML infection, and MS exacerbation may be impossible to discern clinically alone. MRI may provide some clues for distinguishing different pathologies that can be differentiated histologically. In our individual cases, biopsy helped to clarify diagnoses in natalizumab-associated PML.
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Affiliation(s)
- Imke Metz
- Department of Neuropathology, University Medical Center, Georg August University Göttingen, Germany.
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Yoshida M, Hoshina T, Tamura K, Kawano S, Kato T, Sato F, Nakazawa Y, Yoshikawa K, Onodera S, Hori S. An HIV patient with hepatic flare after the initiation of HBV-active antiretroviral therapy. Intern Med 2012; 51:1623-6. [PMID: 22728503 DOI: 10.2169/internalmedicine.51.7244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 39-year-old man presented a CD4 T cell count of 78/µL and HIV-RNA at 6.6 × 10(5) copies/mL at his first medical examination. After the 58th day, we initiated HBV-active antiretroviral therapy. Three months after the start of antiretroviral therapy, he was diagnosed with hepatic flare on the basis of elevated AST and ALT levels without detecting HBV-DNA. Although after continuing the medication his AST and ALT levels increased to 700 IU/L and 1,400 IU/L, respectively, he showed improvement following a natural course and was discharged from hospital after the 169th day. This is a case of hepatic flare likely caused by immune reconstitution associated with resolved HBV infection.
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Affiliation(s)
- Masaki Yoshida
- Department of Infectious Diseases and Infection Control, The Jikei University School of Medicine, Japan.
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Sumatoh HR, Oliver BG, Kumar M, Elliott JH, Vonthanak S, Vun MC, Singh S, Agarwal U, Kumar A, Tan HY, Kamarulzaman A, Yunihastuti E, Saraswati H, Price P. Mycobacterial antibody levels and immune restoration disease in HIV patients treated in South East Asia. Biomark Med 2011; 5:847-53. [PMID: 22103621 DOI: 10.2217/bmm.11.79] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AIM Immune restoration disease (IRD) associated with Mycobacterium tuberculosis parallels the reconstitution of a pathogen-specific Th1 response. However, it is not clear whether humoral responses to M. tuberculosis antigens also rise, or whether antibody levels predict IRD. Here, humoral immunity to M. tuberculosis antigens was investigated in four Asian cohorts. METHODS Plasma samples were obtained from longitudinal prospective studies of HIV patients beginning antiretroviral therapy (ART) in New Delhi (India), Kuala Lumpur (Malaysia), Jakarta (Indonesia) and Phnom Penh (Cambodia). IgG antibodies to purified protein derivative, lipoarabinomannan and 38-kDa antigens of M. tuberculosis were quantitated using in-house ELISAs. IRD was defined as exacerbated symptoms of tuberculosis in patients on anti-tuberculosis therapy or a novel presentation of tuberculosis on ART. RESULTS Pre-ART IgG levels to purified protein derivative, lipoarabinomannan and 38-kDa antigen were similar in the IRD and control groups from each site. Compared with non-IRD controls, a higher proportion of IRD patients had elevated IgG levels to lipoarabinomannan (defined as a greater than twofold increase) over 12 weeks of ART. However, this trend was not significant for the other antigens and longitudinal analyses did not reveal clear rises in antibody levels at the time of IRD. CONCLUSION Levels of antibody to mycobacterial antigens do not predict IRD, but levels of antibody reactive with lipoarabinomannan rise during an IRD in some patients.
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Affiliation(s)
- Hermi R Sumatoh
- School of Pathology & Laboratory Medicine, University of Western Australia, Perth, Australia
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Ali K, Klotz SA. The immune reconstitution inflammatory syndrome with tuberculosis: a common problem in Ethiopian HIV-infected patients beginning antiretroviral therapy. ACTA ACUST UNITED AC 2011; 11:198-202. [PMID: 21521804 DOI: 10.1177/1545109711402212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The Immune Reconstitution Inflammatory Syndrome (IRIS) in Ethiopian HIV-infected patients coinfected with tuberculosis (TB) was studied. HIV-infected outpatients initiating antiretroviral therapy (ART) at an HIV clinic in northern Ethiopia from January 2007 through September 2008 were identified (n = 1977). Patients with TB-IRIS occurring within 6 months of starting ART (n = 143) were compared with a control group of patients with HIV who began ART but did not develop TB-IRIS (n = 277). ART was not interrupted in any patient. Eleven (8%) patients with TB-IRIS died. New or "unmasked" TB with accompanying IRIS occurred in 132 or 92% of the cases. Worsening or "paradoxical" TB (ie, already known to be present and treated) was accompanied by IRIS in 11 (8%) patients. There was no significant difference between "unmasked" and "paradoxical" cases with respect to presentation of disease and outcome. Only a low baseline CD4 count (mean: 102 cells/μL) and a past history of World Health Organization (WHO) Clinical Stage 3 or 4 were associated with TB-IRIS (P < .05). The clinical manifestations of TB-IRIS were diverse, requiring a high index of suspicion. For example, pleural disease occurred in 13 patients, TB lymphadenitis in 17, intracranial TB in 9 patients, and disseminated TB in 15 patients. The majority of patients (88%) responded to continuation of ART and TB therapy. Thus, TB-IRIS is common in Ethiopian patients beginning ART, occurring in 7% of patients initiating antiretroviral therapy.
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Affiliation(s)
- Kedir Ali
- 1Dessie Referral Hospital, Dessie, Ethiopia
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Hibiya K, Tateyama M, Teruya H, Nakamura H, Tasato D, Kazumi Y, Hirayasu T, Tamaki Y, Haranaga S, Higa F, Maeda S, Fujita J. Immunopathological characteristics of immune reconstitution inflammatory syndrome caused by Mycobacterium parascrofulaceum infection in a patient with AIDS. Pathol Res Pract 2011; 207:262-70. [PMID: 21377277 DOI: 10.1016/j.prp.2011.01.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2010] [Revised: 12/21/2010] [Accepted: 01/17/2011] [Indexed: 01/03/2023]
Abstract
Immune reconstitution inflammatory syndrome (IRIS) caused by mycobacterium in patients with AIDS is often experienced in clinical practice. There is, however, a paucity of data documenting the histopathological findings and the pathogenesis. We determined the immunopathological characteristics of IRIS associated with Mycobacterium parascrofulaceum infection in an AIDS patient. A patient presented with pulmonary lymphadenitis and involvement of the pulmonary lingular segment. Portions of the involved lymph nodes and lung were excised, and the immunological properties were analyzed by immunohistochemical assays. The histological characteristics of lymph nodes showed a caseous necrosis. Histopathologically, the pulmonary lesion was composed of exudative and proliferative lesions. CD4(+), CD8(+), CD57(+), and CD25(+)/FoxP3(+) cells were observed in both types of lesions. Clusters of CD20(+) cells and GATA3(+) cells were predominantly observed in exudative lesions, while T-bet(+) cells were dominant in proliferative lesions. ROR-γ(+) cells were also observed in exudative lesions. These results indicate that the cellular immunity to mycobacteria was recovering in the lung tissue. In M. parascrofulaceum pulmonary infection, the exudative lesion had characteristics of Th2 and Th17-type immunities. In contrast, the proliferative lesion had characteristics of Th-1 type immunity. Our data provide the first evidence to reveal the status of the axis of distinctive immunity in the process of granuloma formation caused by a mycobacterium-related infection.
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Affiliation(s)
- Kenji Hibiya
- Department of Infectious, Respiratory, and Digestive Medicine, Control and Prevention of Infectious Diseases, Faculty of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa 903-0215, Japan.
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Yashiro S, Takeda N, Uemura A, Nakamura Y, Kasagi A, Yoshida N, Kikuchi Y, Oka S. [Severe case of cytomegalovirus-associated immune reconstitution syndrome in AIDS]. Nippon Ganka Gakkai Zasshi 2011; 115:34-40. [PMID: 21348231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND Immune reconstitution syndrome (IRS) is a complication caused by reactivation of the immune system that can occur after starting highly active antiretroviral therapy (HAART) in patients with acquired immunodeficiency syndrome (AIDS). Severe IRS associated with cytomegalovirus (CMV) in both eyes who had lost his left vision is reported. CASE A 37-year-old man with AIDS who had started HAART discontinued his medication. Two weeks after the re-induction of HAART, he suffered CMV retinitis OU. Vitreous opacity OU appeared 3 days later, and optic neuritis OS appeared 6 days after the onset; and visual acuity OS decreased to 0.06. As the number of CD 4 positive T lymphocytes (CD 4) increased from 39 to 118/microl in both the pre- and- post HAART, we diagnosed IRS and started anti- CMV and systemic steroid therapy and discontinued the HAART. The focus of CMV retinitis was improved; however, visual acuity OS did not improve. CONCLUSION Severe IRS with visual loss induced by CMV retinitis after HAART needs to be considered in low CD 4 level patients during the induction phase.
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Affiliation(s)
- Shigeko Yashiro
- Department of Ophthalmology, Hospital, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan.
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Bonney DK, O'Meara A, Shabani A, Imrie J, Bigger BW, Jones S, Wraith JE, Wynn RF. Successful allogeneic bone marrow transplant for Niemann-Pick disease type C2 is likely to be associated with a severe 'graft versus substrate' effect. J Inherit Metab Dis 2010; 33 Suppl 3:S171-3. [PMID: 20393800 DOI: 10.1007/s10545-010-9060-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2009] [Revised: 01/19/2010] [Accepted: 01/21/2010] [Indexed: 11/25/2022]
Abstract
Niemann-Pick disease type C2 (NPC2) is caused by the inherited deficiency of a lysosomal cholesterol transport protein, NPC2 protein. Many cases of NPC2 present in early infancy with inflammatory lung disease, with subsequent severe neurological disease and death in early childhood. This disease is theoretically correctable by bone marrow transplantation (BMT), as the NPC2 protein is small and soluble and secreted and recaptured by the mannose-6-phosphate pathway. In this report we describe the first successful allogeneic bone marrow transplantation for this condition in a 16-month-old boy homozygous for the NPC2 p.E20X mutation, which has hitherto been reported to cause disease with a severe phenotype. During BMT there was an initial improvement of the established respiratory illness, with the immune suppression associated with transplant conditioning, but there was subsequent marked deterioration at the time of immune reconstitution and donor cell engraftment. This 'graft versus substrate' reaction was managed with intensive immune suppressant therapy, and it gradually resolved as the substrate was cleared by the engrafted donor macrophages. All immune suppression was withdrawn 18 months after transplantation, and his respiratory illness has resolved. He walked independently at 24 months and is continuing to reach development milestones after receiving his transplant. We conclude that the successful treatment of Niemann-Pick C2 therefore seems likely to be associated with a severe post-transplantation 'graft versus substrate' reaction that requires intense immune suppression before eventual resolution.
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Antonelli LRV, Mahnke Y, Hodge JN, Porter BO, Barber DL, DerSimonian R, Greenwald JH, Roby G, Mican J, Sher A, Roederer M, Sereti I. Elevated frequencies of highly activated CD4+ T cells in HIV+ patients developing immune reconstitution inflammatory syndrome. Blood 2010; 116:3818-27. [PMID: 20660788 PMCID: PMC2981537 DOI: 10.1182/blood-2010-05-285080] [Citation(s) in RCA: 141] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2010] [Accepted: 07/17/2010] [Indexed: 02/07/2023] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) is a considerable problem in the treatment of HIV-infected patients. To identify immunologic correlates of IRIS, we characterized T-cell phenotypic markers and serum cytokine levels in HIV patients with a range of different AIDS-defining illnesses, before and at regular time points after initiation of antiretroviral therapy. Patients developing IRIS episodes displayed higher frequencies of effector memory, PD-1(+), HLA-DR(+), and Ki67(+) CD4(+) T cells than patients without IRIS. Moreover, PD-1(+) CD4(+) T cells in IRIS patients expressed increased levels of LAG-3, CTLA-4, and ICOS and had a Th1/Th17 skewed cytokine profile upon polyclonal stimulation. Elevated PD-1 and Ki67 expression was also seen in regulatory T cells of IRIS patients. Furthermore, IRIS patients displayed higher serum interferon-γ, compared with non-IRIS patients, near the time of their IRIS events and higher serum interleukin-7 levels, suggesting that the T-cell populations are also exposed to augmented homeostatic signals. In conclusion, our findings indicate that IRIS appears to be a predominantly CD4-mediated phenomenon with reconstituting effector and regulatory T cells showing evidence of increased activation from antigenic exposure. These studies are registered online at http://clinicaltrials.gov as NCT00557570 and NCT00286767.
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Affiliation(s)
- Lis R V Antonelli
- Immunobiology Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
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Wang J, Gigliotti F, Bhagwat SP, George TC, Wright TW. Immune modulation with sulfasalazine attenuates immunopathogenesis but enhances macrophage-mediated fungal clearance during Pneumocystis pneumonia. PLoS Pathog 2010; 6:e1001058. [PMID: 20808846 PMCID: PMC2924364 DOI: 10.1371/journal.ppat.1001058] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2010] [Accepted: 07/22/2010] [Indexed: 11/18/2022] Open
Abstract
Although T cells are critical for host defense against respiratory fungal infections, they also contribute to the immunopathogenesis of Pneumocystis pneumonia (PcP). However, the precise downstream effector mechanisms by which T cells mediate these diverse processes are undefined. In the current study the effects of immune modulation with sulfasalazine were evaluated in a mouse model of PcP-related Immune Reconstitution Inflammatory Syndrome (PcP-IRIS). Recovery of T cell-mediated immunity in Pneumocystis-infected immunodeficient mice restored host defense, but also initiated the marked pulmonary inflammation and severe pulmonary function deficits characteristic of IRIS. Sulfasalazine produced a profound attenuation of IRIS, with the unexpected consequence of accelerated fungal clearance. To determine whether macrophage phagocytosis is an effector mechanism of T cell-mediated Pneumocystis clearance and whether sulfasalazine enhances clearance by altering alveolar macrophage phagocytic activity, a novel multispectral imaging flow cytometer-based method was developed to quantify the phagocytosis of Pneumocystis in vivo. Following immune reconstitution, alveolar macrophages from PcP-IRIS mice exhibited a dramatic increase in their ability to actively phagocytose Pneumocystis. Increased phagocytosis correlated temporally with fungal clearance, and required the presence of CD4(+) T cells. Sulfasalazine accelerated the onset of the CD4(+) T cell-dependent alveolar macrophage phagocytic response in PcP-IRIS mice, resulting in enhanced fungal clearance. Furthermore, sulfasalazine promoted a TH2-polarized cytokine environment in the lung, and sulfasalazine-enhanced phagocytosis of Pneumocystis was associated with an alternatively activated alveolar macrophage phenotype. These results provide evidence that macrophage phagocytosis is an important in vivo effector mechanism for T cell-mediated Pneumocystis clearance, and that macrophage phenotype can be altered to enhance phagocytosis without exacerbating inflammation. Immune modulation can diminish pulmonary inflammation while preserving host defense, and has therapeutic potential for the treatment of PcP-related immunopathogenesis.
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Affiliation(s)
- Jing Wang
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, United States of America
| | - Francis Gigliotti
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, United States of America
- Department of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, New York, United States of America
| | - Samir P. Bhagwat
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, United States of America
| | | | - Terry W. Wright
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, United States of America
- Department of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, New York, United States of America
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Cabral RF, Valle Bahia PR, Gasparetto EL, Chimelli L. Immune reconstitution inflammatory syndrome and cerebral toxoplasmosis. AJNR Am J Neuroradiol 2010; 31:E65-6. [PMID: 20507930 DOI: 10.3174/ajnr.a2158] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Sharma SK, Dhooria S, Barwad P, Kadhiravan T, Ranjan S, Miglani S, Gupta D. A study of TB-associated immune reconstitution inflammatory syndrome using the consensus case-definition. Indian J Med Res 2010; 131:804-808. [PMID: 20571170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023] Open
Abstract
BACKGROUND & OBJECTIVES A considerable proportion of patients with HIV associated tuberculosis (TB) started on highly active antiretroviral therapy (HAART) develop immune reconstitution inflammatory syndrome (IRIS), which is difficult to diagnose in a resource-limited setting. In view of the recently proposed consensus case-definitions for TB-IRIS for use in resource-limited settings we undertook this study to describe the incidence and risk factors of TB associated IRIS in a tertiary care hospital and research centre in north India. METHODS Retrospective analysis of antiretroviral treatment (ART) naïve adults started on highly active ART (HAART) from June 2006 to September 2008 was done. RESULTS Of the 627 patients studied, 237 (38%) had TB at the initiation of HAART. In total, 18 (7.5%) of 237 patients with TB at baseline had paradoxical TB-associated IRIS, and 12 (3%) of 390 patients without TB at baseline developed ART-associated TB. Most IRIS events occurred during the initial 30 days of HAART. Two patients developed TB-associated IRIS after 90 days of HAART. Using univariate analysis, low CD4+ cell count at baseline [64 (28-89) vs. 95 (52-150); P=0.009] and early initiation of HAART [33 (24-41) vs. 48 (35-61) days; P<0.001] were significantly associated with paradoxical TB-associated IRIS. No identifiable risk factors were associated with the development of ART-associated TB. INTERPRETATION & CONCLUSION A considerable proportion of patients on HAART develop TB-associated IRIS. The consensus case-definition is a useful tool in resource-limited settings for the diagnosis of TB- associated IRIS.
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Affiliation(s)
- Surendra K Sharma
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India.
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Pornprasert S, Leechanachai P, Klinbuayaem V, Leenasirimakul P, Promping C, Inta P, Ajhan S. Unmasking tuberculosis-associated immune reconstitution inflammatory syndrome in HIV-1 infection after antiretroviral therapy. Asian Pac J Allergy Immunol 2010; 28:206-209. [PMID: 21038792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The exaggerated immune response to the subclinical opportunistic microorganisms or their antigens can be found in HIV-1 infected patients after receiving antiretroviral (ARV) therapy. We report a case of unmasking tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) in the HIV-1 infected patient who had no previous history of mycobacterial infection. She had tuberculosis of intestines, peritoneum and mesenteric glands within 2 months of ARV. However, her sputum acid-fast bacilli stain, sputum, blood and cervical lymph node aspiration cultures for mycobacterium were negative. Her CD4 cell count increased of from 46 cells/microL at baseline before receiving ARV to 155 cells/microL at month 6 of ARV. In addition, her plasma pro-inflammatory (IFN-gamma and TNF-alpha) and anti-inflammatory (IL-10) cytokine measurement was supported the occurrence of immune restoration reaction. Therefore, the changing in these cytokine profiles may be an important marker of developing unmasking TB-IRIS.
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Affiliation(s)
- Sakorn Pornprasert
- Faculty of Associated Medical Sciences, Chiang-Mai University, Chiang-Mai.
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Deps P, Lockwood DNJ. Leprosy presenting as immune reconstitution inflammatory syndrome: proposed definitions and classification. LEPROSY REV 2010; 81:59-68. [PMID: 20496570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Affiliation(s)
- Patricia Deps
- Department of Social Medicine/Service of Dermatology, Federal University of Espirito Santo, Vitoria-ES, Brazil.
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