Browsing by Author "Meintjes, Graeme"
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- ItemOpen AccessAdult meningitis in a setting of high HIV and TB prevalence: findings from 4961 suspected cases(BioMed Central Ltd, 2010) Jarvis, Joseph; Meintjes, Graeme; Williams, Anthony; Brown, Yolande; Crede, Tom; Harrison, ThomasBACKGROUND: The presentation and causes of adult meningitis in South Africa have changed substantially as a result of HIV. Knowledge of aetiology and laboratory findings in patients presenting with meningitis are important in guiding management. We performed a retrospective study to determine these findings in a setting of high HIV and TB prevalence in Cape Town. METHODS: Patients undergoing lumbar punctures between 1st January 2006 and 31st December 2008 at a public sector referral hospital were studied. Cases were classified by microbiological diagnosis, or in the absence of definitive microbiology as 1) normal CSF (neutrophils [less than or equal to] 1 x 106/L, lymphocytes [less than or equal to] 5 x 106/L, protein [less than or equal to] 0.5 g/dL, glucose [greater than or equal to]1.5 mmol/L), 2) minor abnormalities (neutrophils 2-5, lymphocytes 6-20, protein 0.51-1.0, glucose 1.0-1.49) or 3) markedly abnormal (neutrophils>5, lymphocytes>20, protein>1.0, glucose<1.0). RESULTS: 5578 LPs were performed on 4549 patients, representing 4961 clinical episodes. Of these, 2293 had normal CSF and 931 had minor abnormalities and no aetiology identified. Of the remaining 1737, microbiological diagnoses were obtained in 820 (47%). Cryptococcus accounted for 63% (514) of microbiological diagnoses, TB for 28% (227), bacterial meningitis for 8% (68). Of the remaining 917 who had marked abnormalities, the majority (59%) had a sterile lymphocytic CSF. Of note 16% (81) patients with confirmed Cryptococcus, 5% (12) with TB and 4% (3) with bacterial meningitis had normal CSF cell-counts and biochemistry. CONCLUSIONS: Cryptococcal and tuberculous meningitis are now the commonest causes of adult meningitis in this setting. TB meningitis is probably underdiagnosed by laboratory investigation, as evidence by the large numbers presenting with sterile lymphocytic markedly abnormal CSFs.
- ItemOpen AccessAltered ratio of IFN-γ/IL-10 in patients with drug resistant Mycobacterium tuberculosis and HIV-tuberculosis immune reconstitution inflammatory syndrome(Public Library of Science, 2012) Skolimowska, Keira H; Rangaka, Molebogeng X; Meintjes, Graeme; Pepper, Dominique J; Seldon, Ronnett; Matthews, Kerryn; Wilkinson, Robert J; Wilkinson, Katalin AWe have described a clinical relationship between HIV-Tuberculosis Immune Reconstitution Inflammatory Syndrome (TB-IRIS) and anti-tubercular drug resistance. Here we studied the immune response of TB-IRIS patients from whom a drug-resistant (n = 11) or drug-susceptible (n = 25) Mycobacterium tuberculosis (MTB) strain was isolated after presenting with TB-IRIS. ELISpot analysis and multiplex cytokine analysis of the supernatant collected from peripheral blood mononuclear cells stimulated overnight with the heat-killed H37Rv MTB laboratory strain was used. Although there was no statistical difference in IFN-gamma ELISpot responses between the two groups, the results point towards higher bacterial load in the drug-resistant patients, possibly due to failed therapy. The ratio between secreted IFN-gamma/IL-10 and IL-2/IL-10 was significantly lower in TB-IRIS patients in whom the cause of TB was a drug-resistant strain compared to those with a fully sensitive strain (p = 0.02). Since host immune responses are dependent on the bacterial load, we hypothesise that the impaired cytokine balance is likely to be caused by the poorly controlled bacterial growth in these patients.
- ItemOpen AccessAn evidence-based algorithm for the rapid diagnosis of tuberculosis in HIV positive patients presenting to emergency centres(2021) van Hoving, Daniël J; Meintjes, Graeme; Maartens, Gary; Kenge, AndreBackground Tuberculosis remains a prevalent and deadly global disease. Diagnostic delays are partly due to reduced diagnostic performance of tuberculosis tests in HIV-positive people. The use of reliable pointof-care and near-patient diagnostic tests (e.g. urine lipoarabinomannan and point-of-care ultrasound) are increasingly being used and would benefit patients presenting to emergency centres by rapidly diagnosing HIV-associated tuberculosis. Methods Two studies were done: i) A systematic (Cochrane) review was done to determine the diagnostic accuracy of abdominal ultrasound for detecting abdominal tuberculosis or disseminated tuberculosis with abdominal involvement in HIV-positive individuals, and ii) A cross-sectional diagnostic study to derive a multi-parameter clinical decision tree, incorporating clinical information, point-of-care ultrasound features, chest x-ray and urine lateral flow lipoarabinomannan. The cross-sectional study was performed at the emergency centre of Khayelitsha Hospital, a South African district-level hospital in a high HIV-prevalence community, and resulted in three different publications. Consecutive HIV-positive adults presenting with ≥1 WHO tuberculosis symptoms were enrolled over a 16-month period (June 2016 to October 2017). Demographic and clinical information was recorded on a standardized data collection form. Point-of-care ultrasound was performed according to a standardized protocol. Urine lipoarabinomannan assays were done at point-of-care by emergency physicians and repeated in the laboratory. Chest x-rays were reviewed by a single radiologist using a standardized assessment form. The reference standard was a positive tuberculosis culture or Xpert MTB/RIF test on sputum, or appropriate extra-pulmonary samples. We compared diagnostic accuracy and reproducibility of urine lipoarabinomannan between point-ofcare readers and laboratory readers. We determined the diagnostic accuracy of individual point-ofcare ultrasound features, performed an external validation of the focused assessment with sonography for HIV/TB (FASH) protocol, and determined independent point-of-care ultrasound predictors of HIV-associated tuberculosis. We derived the decision tree model from multivariable logistic regression models. Results Abdominal ultrasound had a pooled sensitivity of 63% (95%CI 43-79; 5 studies, 368 participants; very low-certainty evidence) and a pooled specificity of 68% (95%CI 42-87; 5 studies, 511 participants; very low-certainty evidence) for bacteriologically confirmed tuberculosis. We screened 556 patients in the cross-sectional study of whom 414 (74.5%) were enrolled. The prevalence of microbiologically confirmed tuberculosis was 41.5% (n=172). Point-of-care and laboratory-performed urine lipoarabinomannan had similar sensitivity (41.8% vs 42.0%, P=1.0) and specificity (90.5% vs 87.5%, P=0.23). Moderate agreement was found between point-of-care and laboratory testing (k=0.62), but there was strong agreement between point-of-care readers (k=0.95) and between laboratory readers (k=0.94). Sensitivity and specificity of ≥1 individual point-of-care ultrasound feature were 73% (95%CI 65-79) and 54% (95%CI 47-60), and of the FASH protocol 71% (95%CI 64-78) and 57% (95%CI 50-63). Independent point-of-care ultrasound predictors identified were intra-abdominal lymphadenopathy of any size (aDOR 3.7; 95%CI 2.0-6.7), ascites (aDOR 3.0; 95%CI 1.5-5.7), and pericardial effusion of any size (aDOR 1.9; 95%CI 1.2-3.0). Two or more independent point-of-care ultrasound predictors had 33% (95%CI 27–41) sensitivity and 91% (95%CI 86-94) specificity. The best performing model included WHO screening symptoms ≥2, antiretroviral therapy use, urinary lipoarabinomannan, independently predictive point-of-care ultrasound features (ascites, any size pericardial effusion, any size intra-abdominal lymphadenopathy), and chest x-ray (c-statistic 0.82; 95%CI 0.78–0.86). Adding CD4 cell count did not improve the performance of the model. Classification And Regression Tree (CART) analysis positioned urinary lipoarabinomannan as the optimal screening test after WHO symptoms (75% true positive rate, representing 17% of participants). Conclusion An evidence-based algorithm for the rapid diagnosis of tuberculosis in HIV-positive patients presenting to an emergency centre was developed. Urinary lipoarabinomannan can be reliably performed at the point-of-care since there was no diagnostic accuracy advantage in laboratory-performed versus pointof-care–performed tests. The role of ultrasound in diagnosing HIV-associated tuberculosis had limitations. The low sensitivity of ultrasound (63% in the systematic review; 73% in the cross-sectional study) and the moderate discrimination (specificity 91%) of the presence of ≥2 independent point-ofcare ultrasound predictors indicate that point-of-care ultrasound results should be interpreted in combination with other diagnostic information. The derived decision tree can facilitate the immediate initiation of anti-tuberculosis treatment in about a quarter of patients among whom 75% would have a definitive diagnosis of tuberculosis regardless of CD4 cell count. The 30% false negative rate indicates that the algorithm should not be used to exclude tuberculosis. The performance of the decision tree needs to be further evaluated in settings with a different prevalence of HIV-associated tuberculosis.
- ItemOpen AccessAntiretroviral treatment outcomes amongst older adults in a large multicentre cohort in South Africa(Public Library of Science, 2014) Fatti, Geoffrey; Mothibi, Eula; Meintjes, Graeme; Grimwood, AshrafIntroduction Increasing numbers of patients are starting antiretroviral treatment (ART) at advanced age or reaching advanced age while on ART. We compared baseline characteristics and ART outcomes of older adults (aged ≥55 years) vs. younger adults (aged 25-54 years) in routine care settings in South Africa. METHODS: A multicentre cohort study of ART-naïve adults starting ART at 89 public sector facilities was conducted. Mortality, loss to follow-up (LTFU), immunological and virological outcomes until five years of ART were compared using competing-risks regression, generalised estimating equations and mixed-effects models. RESULTS: 4065 older adults and 86,006 younger adults were included. There were more men amongst older adults; 44.7% vs. 33.4%; RR = 1.34 (95% CI: 1.29-1.39). Mortality after starting ART was substantially higher amongst older adults, adjusted sub-hazard ratio (asHR) = 1.44 over 5 years (95% CI: 1.26-1.64), particularly for the period 7-60 months of treatment, asHR = 1.73 (95% CI: 1.44-2.10). LTFU was lower in older adults, asHR = 0.87 (95% CI: 0.78-0.97). Achievement of virological suppression was greater in older adults, adjusted odds ratio = 1.42 (95% CI: 1.23-1.64). The probabilities of viral rebound and confirmed virological failure were both lower in older adults, adjusted hazard ratios = 0.69 (95% CI: 0.56-0.85) and 0.64 (95% CI: 0.47-0.89), respectively. The rate of CD4 cell recovery (amongst patients with continuous viral suppression) was 25 cells/6 months of ART (95% CI: 17.3-33.2) lower in older adults. CONCLUSIONS: Although older adults had better virological outcomes and reduced LTFU, their higher mortality and slower immunological recovery warrant consideration of age-specific ART initiation criteria and management strategies.
- ItemOpen AccessAssessment at antiretroviral clinics during TB treatment reduces loss to follow-up among HIV-infected patients(Public Library of Science, 2012) Pepper, Dominique J; Marais, Suzaan; Bhaijee, Feriyl; Wilkinson, Robert J; De Azevedo, Virginia; Meintjes, GraemeSetting: A South African township clinic where loss to follow-up during TB treatment may prevent HIV-infected TB patients from receiving life-saving ART. Objective: To determine factors associated with loss to follow-up during TB treatment. Design: Regression analyses of a cohort of ART-eligible TB patients who commenced TB treatment and were followed for 24 weeks. RESULTS: Of 111 ART-eligible TB patients, 15 (14%) died in the ensuing 24 weeks. Of the remaining 96 TB patients, 11 (11%) were lost to follow-up. All TB patients lost to follow-up did not initiate ART. Of 85 TB patients in follow-up, 62 (73%) initiated ART 56 days after TB diagnosis (median, IQR 33-77 days) and 31 days after initial assessment at an ART clinic (median, IQR: 18-55 days). The median duration from TB diagnosis to initial assessment at an ART clinic was 19 days (IQR: 7-48 days). At 24 weeks, 6 of 85 (7%) TB patients who presented to an ART clinic for assessment were lost to follow-up, compared to 5 of 11 (45%) TB patients who did not present to an ART clinic for assessment. Logistic regression analysis (adjusted odds ratio  = 0.1, 95% confidence interval [95% CI]: 0.03-0.66) and our Cox proportional hazards model (hazard ratio  = 0.2, 95% CI: 0.04-0.68) confirmed that assessment at an ART clinic during TB treatment reduced loss to follow-up. CONCLUSION: Assessment at antiretroviral clinics for HIV care by trained health-care providers reduces loss to follow-up among HIV-infected patients with TB.
- ItemOpen AccessAssessment of lung function abnormalities in adult patients with tuberculosis in a high HIV-prevalent setting and the impact of a pulmonary rehabilitation intervention to improve lung function, functional capacity, and quality of life(2022) Manie, Shamila; Amosun, Seyi Ladele; Meintjes, Graeme; Allwood, Brian; Zinyakatira, NesbertBackground: Globally, tuberculosis (TB) continues to be a major health problem. In the most recent World Health Organisation (WHO) Global Tuberculosis Report of 2019, TB was ranked as the leading cause of death from an infectious disease ahead of the human immunodeficiency virus (HIV) and acquired immune-deficiency syndrome (AIDS). In the 2019 WHO Global Report on TB, there is little information relating to TB post-cure effects and management. Although there is evidence that successful completion of TB treatment does not equate to normal lung function, there is growing need for research, both during and after TB treatment, on the extent of lung function abnormalities and how these impact on the individual's quality of life (QoL). Pulmonary rehabilitation programmes may provide a continuum of care for individuals with TB to address both lung function abnormalities as well as positively impacting on QoL. Objectives: The present PhD thesis aimed to provide insight into the extent of pulmonary disease in individuals with pulmonary TB during and near completion of TB treatment as well as to establish whether provision of a pulmonary rehabilitation programme (PRP) could address the research gap. To achieve this, three linked studies were undertaken in the form of observational (prevalence) study (Study 1), a systematic review (Study 2), and a randomised control trial (Study 3). Study One: Observational Study Objectives: The overall aim of the present observational study was to ascertain the prevalence of lung function abnormalities in first time, drug sensitive individuals living with TB, with or without HIV coinfection, at near completion (at least four months) of TB treatment. The specific objectives were to determine: i) baseline clinical and socio-economic profile, ii) baseline information pertaining to the QoL outcome measures of EQ-5D-3L and the St George's Respiratory Questionnaire (SGRQ), iii) measure lung function parameters, iv) establish the proportion of participants with normal or abnormal (obstructive, restrictive, or mixed) lung function and the severity of these, v) whether a correlation of lung function abnormalities with chest x-ray (CXR) abnormalities exist, vi) establish whether a relationship exists between lung function and QoL measures, and vii) identify the predictors of lung function abnormality in individuals being treated for active TB. Methods: A cross-sectional observational study using a sample of convenience was conducted. Inclusion criteria included all adult male and females between the age of 18-80 years with confirmed (smear positive or by CXR) drug-susceptible TB who were receiving treatment, with or without HIV coinfection, for at least four months (16 weeks). ii Participants were excluded from Study 1 if they were adult patients who had had previous TB episodes, recent severe chest trauma (within the previous three months), a recent history of pneumonia, known atopic asthma, chronic bronchitis, emphysema, bronchiectasis prior to TB diagnosis, cardiac failure, or any other unrelated respiratory disease as reported in their medical folder. Participants completed two QoL questionnaires (EQ-5D-3L and SGRQ), a self-designed clinical research form to collect descriptive data, a six-minute walk test (6MWT), CXR, and spirometry once off. Results: The sample of 305 participants were predominantly male (n=168:55; 1%), had a median age of 36 years (IQR:28-43), and had median time of 19 weeks (IQR:18-22) on TB treatment. Overall, 32% of the sample presented with abnormal lung function (obstructive=11%, restrictive=15%, and mixed=6%). Only 2.2% of the total sample had two or more co-morbidities. There was no statistically significant difference (p=0.29) in distance covered by participants who had obstructive compared to restrictive lung function abnormality. After logistic regression analysis of clinical and sociodemographic variables (multi-variate), only being older (56–65 years old) and being obese were statistically significant (p=0.02 and p=0.04 respectively). When considering QoL, only the domain of mobility for the EQ-5D-3L questionnaire was statistically associated with abnormal lung function (p=0.02). Linear regression modelling for continuous variables of lung function (FEV1, FVC, FEV1/FVC and percentage predicted of FEV1, FVC, and FEV1/FVC) with SGRQ, 6MWD, and CXR scores yielded no predictor. Conclusion: Overall, 32% of participants presented with abnormal lung function, which is lower than comparator studies investigating lung function in TB populations. Quality of life measures for most participants was considered good at the time of assessment. Limitations to Study 1 related to the absence of normative data for a healthy population relating to lung function and 6MWD to compare the findings in this TB population. Recommendations for future research would be to establish normative data for these outcome measures. Regarding lung function testing, it is recommended that training of correct execution of the spirometry techniques is performed prior to assessment as the technique may be unfamiliar compared to the routine tests done at clinic visits for individuals receiving TB treatment. iii Study Two: Systematic Narrative Review A systematic review was conducted to establish the evidence of the impact of non-pharmacological intervention programmes (pulmonary rehabilitation) in the rehabilitation of individuals living with TB on lung function outcomes. Methods: MEDLINE via Pubmed, CENTRAL, CINAHL, PEDro, Web of Science, Scopus, Science Direct, and African Index Medicus, including Google Scholar were searched (from January 1995 to December 2016 with an updated search in November 2018) for randomised control trials, quasi-experimental and pre-post-test studies on PRPsfor adult individuals with TB specifically with lung function measures as primary outcome. Results: In total, 1 705 studies were obtained from the search. Once duplicate studies were removed, 1 220 studies remained. The titles and abstracts of these studies were screened resulting in 1 210 studies being excluded. Therefore, 10 studies were potentially eligible. Once the full-text articles were assessed, four studies met the inclusion criteria. Of the included studies, only one was a randomised control trial, two studies were single arm before and after studies, and one study was a prospective non-randomised open trial (two arms). In total, there were 178 participants in these studies, with sample sizes ranging from 10 to 67 participants. All four selected studies had both male and female participants; however, overall, male participants were the majority with 69% versus 21% females. The mean age across the studies was 70 years. No statistically significant difference (p>0.05) was found regarding lung function parameters and the PRPs. No meta-analysis could be performed as data could not be pooled due to the differences in study characteristics and outcome measures. Conclusion: This review was unable to support or negate the use of pulmonary rehabilitation for individuals with TB primarily due to the lack of well-designed and executed randomised control trials. The studies showed that no effect on FEV1 was demonstrated. The researchers recommended that future research investigates the extent of pulmonary sequelae in patients after completion of TB chemotherapy in large-scale studies. Long-term follow-up in those who have had TB without surgical intervention should be prioritised to see the extent of lung function disorders in this population, particularly in countries on the high-burden list for the disease. A further recommendation is that well executed randomised control trials that control for biases to investigate pulmonary rehabilitation in populations of individuals with TB should be prioritised as there is a need to develop an evidencebased continuum of care. iv Study Three: Randomised Controlled Trial Objectives: The overall objective of study three was to determine what the impact of a contextually relevant PRP would have on individuals living with TB, with or without HIV co-infection, on outcomes related to lung function, functional capacity, and QoL. Methods: A pilot randomised, single blinded, pre-test-post-test design was used. Inclusion criteria were all adult males and females between 18-65 years with TB confirmed by Gene Xpert, irrespective of number of TB episodes, HIV status, or having chronic obstructive pulmonary disease. Participants had to be within their first week of TB treatment. Participants with only extra-pulmonary TB, recent severe chest trauma (within the last three months), a recent history of pneumonia (within one month), known atopic asthma, cardiac failure, or any other unrelated respiratory disease as reported in their medical folders or who had defaulted on their treatment were excluded. In addition to this, if participants failed the pre-participation health screening and were non-ambulate due to paralysis or amputation, they were also excluded. Fifty-eight participants were randomised into a control group (CG) receiving only pharmacological therapy and the intervention group (IG) who received pulmonary rehabilitation in addition to pharmacological therapy. The PRP was held for 12 weeks and consisted of two weekly sessions with a duration of 45 minutes each, which was delivered at a community centre. Participants completed two QoL questionnaires (EQ-5D-3L and SGRQ), a self-designed clinical research form to collect descriptive data, a three-minute step test, and spirometry at three time points (enrolment, at six weeks, and at 12 weeks). T-tests were conducted to determine the difference between means of the CG and IG for lung function parameters, functional capacity, and QoL outcomes. Results: There were 29 participants in each group. Regarding sex, age, and number of co-morbidities the two groups were well matched. Regarding HIV status, the CG had more participants that were HIV positive (n=22) and on anti-retroviral therapy (n=11) than their IG counterparts (n=13 and n=5 respectively). Nearly half of the participants had a first time TB diagnosis, with the participants in the IG having reported more recurring TB incidences overall (n=16 vs. n=13). A t-test for difference between means showed no statistical significance for the CG and IG regarding FEV1, FVC, and FEV1/FVC ratio for absolute or percentage predicted values. Forty-three percent of participants in the total sample had normal lung function at baseline, with the remaining participants being classified as having either obstructive (26%), restrictive (21%), or mixed (10%) lung function. At baseline, 48% of participants in the CG had abnormal lung function compared to 67% in the IG. At six weeks there was no change in the CG regarding lung abnormalities. However, the IG only had 33% abnormal lung function at the same time point. v Although there was no statistical significance for any of the lung function categories, there was a 42% improvement in normal lung function at six weeks in the IG compared to the CG at baseline. The median baseline number of steps taken by the CG was 79 steps (IQR:42-134) compared to 117 steps by the IG (IQR:84-154). A t-test conducted to test the difference between means for the CG and IG was statistically significant for the step test (p=0.002) at six weeks for the IG, but not at 12 weeks (p=0.13). No correlation was found between the SGRQ (QoL parameter) and any lung function parameter (p>0.05) at 12 weeks. Conclusion: Although the changes in lung function, functional capacity, and QoL did not reach statistical significance at completion of the PRP for the IG, the continued improvement in all the outcomes for the IG from 0 weeks to 12 weeks holds potential clinical significance.
- ItemOpen AccessBarriers to initiation of antiretrovirals during antituberculosis therapy in Africa(Public Library of Science, 2011) Pepper, Dominique J; Marais, Suzaan; Wilkinson, Robert J; Bhaijee, Feriyl; De Azevedo, Virginia; Meintjes, GraemeBACKGROUND: In the developing world, the principal cause of death among HIV-infected patients is tuberculosis (TB). The initiation of antiretroviral therapy (ART) during TB therapy significantly improves survival, however it is not known which barriers prevent eligible TB patients from initiating life-saving ART. Method Setting. A South African township clinic with integrated tuberculosis and HIV services. Design. Logistic regression analyses of a prospective cohort of HIV-1 infected adults (≥18 years) who commenced TB therapy, were eligible for ART, and were followed for 6 months. FINDINGS: Of 100 HIV-1 infected adults eligible for ART during TB therapy, 90 TB patients presented to an ART clinic for assessment, 66 TB patients initiated ART, and 15 TB patients died. 34% of eligible TB patients (95%CI: 25-43%) did not initiate ART. Male gender and younger age (<36 years) were associated with failure to initiate ART (adjusted odds ratios of 3.7 [95%CI: 1.25-10.95] and 3.3 [95%CI: 1.12-9.69], respectively). Death during TB therapy was associated with a CD4+ count <100 cells/µL. CONCLUSION: In a clinic with integrated services for tuberculosis and HIV, one-third of eligible TB patients - particularly young men - did not initiate ART. Strategies are needed to promote ART initiation during TB therapy, especially among young men.
- ItemOpen AccessCerebrospinal Fluid Cytokine Profiles Predict Risk of Early Mortality and Immune Reconstitution Inflammatory Syndrome in HIV-Associated Cryptococcal Meningitis(Public Library of Science, 2015) Jarvis, Joseph N; Meintjes, Graeme; Bicanic, Tihana; Buffa, Viviana; Hogan, Louise; Mo, Stephanie; Tomlinson, Gillian; Kropf, Pascale; Noursadeghi, Mahdad; Harrison, Thomas SAuthor Summary 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.
- ItemOpen AccessCharacterization of and risk factors for HIV-1 resistance mutations following first line antiretroviral failure in the southern African private sector(2017) Lutaaya, Leonard Edgar; Meintjes, Graeme; Wallis, Carole LBackground: First-line antiretroviral therapy (ART) regimen choices have evolved over the past 15 years in South Africa. Many patients develop HIV drug resistance mutations when they fail first-line ART. The effect of different drug regimens and other patient related factors on drug resistant mutations selected at first line failure are not well characterised in Southern Africa with its predominantly subtype C epidemic. Objectives: To characterize HIV resistance mutations in patients failing first-line ART in the private sector in Southern Africa, and risk factors associated with resistance and particular resistance mutations. Methods: This was a retrospective observational study linking two databases. One database was that of the Aid for AIDS (AfA) disease management programme (for clinical and ART regimen data) and the other was that of Lancet Laboratories where HIV genotypic sequence data were stored. Variables included in analyses were age, gender, province, WHO stage at time of resistance testing (HIVDR), duration of ART at HIVDR, prior monotherapy or dual therapy, viral load and CD4 count prior to starting ART, viral load and CD4 count at HIVDR, duration that the viral load was >400 copies/ml prior to HIVDR and HIV subtype. Data on patients who had a resistance test between 2008 and 2014 while failing first line ART was extracted from these databases. Fisher's exact test and Chi-squared test were used to analyse categorical variables and Wilcoxon rank sum test for continuous variables. For multivariate analyses, logistic regression models were used. Results: Patients who registered with AfA between 1998 and 2013 and had a resistance test performed whilst experiencing viral failure on a non-nucleoside reverse transcriptase inhibitor (NNRTI) regimen with no history of prior failure on a protease inhibitor (PI) regimen were included: 265 (95.3%) patients had a reverse transcriptase mutation of any kind, 253 (91%) had an NNRTI mutation and 246 (88.5%) had a nucleoside reverse transcriptase inhibitor (NRTI) mutation (n=278). The commonest mutation was the M184V mutation (80.6%), 44.2% had at least one thymidine analogue mutation (TAM) and 42.1% had the K103N/S mutation. Notably there was a median of 18 months during which the viral load was not suppressed prior to the resistance tests, which likely contributed to the high prevalence of mutations. A total of 83 (29.9%) patients were found to have the K65R mutation, 72 of these patients were on tenofovir (TDF) at the time of resistance testing demonstrating the strong association between TDF and the K65R mutation. Conclusions: The mutational patterns observed in our study and their prevalence were similar to those noted in previous studies done within the region's public sector. There was a high prevalence of the K65R mutation in patients failing TDF-containing regimens. A longer duration on ART and failing ART were correlated with an increased number of TAMs.
- ItemOpen AccessClinical and financial burdens of secondary level care in a public sector antiretroviral roll-out setting (G F Jooste Hospital)(Academy of Science of South Africa, 2009) Kevany, Sebastian; Meintjes, Graeme; Rebe, Kevin; Maartens, Gary; Cleary, SusanBackground: Antiretroviral therapy (ART) is being extended across South Africa. While efforts have been made to assess the costs of providing ART via accredited service points, little information is available on its downstream costs, particularly in public secondary level hospitals. Objectives: To determine the cost of care for inpatients and outpatients at a dedicated antiretroviral referral unit treating and caring for antiretroviral-related conditions in a South African peri-urban setting; to identify key epidemiological cost drivers; and to examine the associated clinical and outcome data. Methods: A prospective costing study on 48 outpatients and 25 inpatients was conducted from a health system perspective. Incremental economic costs and clinical data were collected from primary sources at G F Jooste Hospital, Cape Town, over a 1-month period (March 2005). Results: Incremental cost per outpatient was R1 280, and per inpatient R5 802. Costs were dominated by medical staff costs (62% inpatient and 58% outpatient, respectively). Infections predominated among diagnoses and costs – 55% and 67% respectively for inpatients, and 49% and 54% respectively for outpatients. Most inpatients and outpatients were judged by attending physicians to have improved or stabilised as a result of treatment (52% and 59% respectively). Conclusions. The costs of providing secondary level care for patients on or immediately preceding ART initiation can be significant and should be included in the government’s strategic planning: (i) so that the service can be expanded to meet current and future needs; and (ii) to avoid crowding out other secondary level health services.
- ItemOpen AccessClinical deterioration during antitubercular treatment at a district hospital in South Africa: the importance of drug resistance and AIDS defining illnesses(Public Library of Science, 2009) Pepper, Dominique J; Rebe, Kevin; Morroni, Chelsea; Wilkinson, Robert J; Meintjes, GraemeBACKGROUND: Clinical deterioration on drug therapy for tuberculosis is a common cause of hospital admission in Africa. Potential causes for clinical deterioration in settings of high HIV-1 prevalence include drug resistant Mycobacterium tuberculosis (M.tb) , co-morbid illnesses, poor adherence to therapy, tuberculosis associated-immune reconstitution inflammatory syndrome (TB-IRIS) and subtherapeutic antitubercular drug levels. It is important to derive a rapid diagnostic work-up to determine the cause of clinical deterioration as well as specific management to prevent further clinical deterioration and death. We undertook this study among tuberculosis (TB) patients referred to an adult district level hospital situated in a high HIV-1 prevalence setting to determine the frequency, reasons and outcome for such clinical deterioration. Method A prospective observational study conducted during the first quarter of 2007. We defined clinical deterioration as clinical worsening or failure to stabilise after 14 or more days of antitubercular treatment, resulting in hospital referral. We collected data on tuberculosis diagnosis and treatment, HIV-1 status and antiretroviral treatment, and investigated reasons for clinical deterioration as well as outcome. RESULTS: During this period, 352 TB patients met inclusion criteria; 296 were admitted to hospital accounting for 17% of total medical admissions (n = 1755). Eighty three percent of TB patients (291/352) were known to be HIV-1 co-infected with a median CD4 count of 89cells/mm 3 (IQR 38-157). Mortality among TB patients admitted to hospital was 16% (n = 48). The median duration of hospital admission was 9.5 days (IQR 4-18), longer than routine in this setting (4 days). Among patients in whom HIV-1 status was known (n = 324), 72% of TB patients (n = 232) had an additional illness to tuberculosis; new AIDS defining illnesses (n = 80) were the most frequent additional illnesses (n = 208) in HIV-1 co-infected patients (n = 291). Rifampin-resistant M.tb (n = 41), TB-IRIS (n = 51) and drug resistant bacterial infections (n = 12) were found in 12%, 14% and 3.4% of the 352 cases, respectively. Interpretation In our setting, new AIDS defining illnesses, drug resistant M.tb and other drug resistant bacteria are important reasons for clinical deterioration in HIV-1 co-infected patients receiving antitubercular treatment. HIV-1 co-infected patients may be at increased risk of acquiring nosocomial drug resistant pathogens because profound immune suppression results in co-morbid illnesses that require prolonged inpatient admissions. Routine infection control is essential and needs to be strengthened in our setting.
- ItemOpen AccessClinical deterioration during antituberculosis treatment in Africa: Incidence, causes and risk factors(BioMed Central Ltd, 2010) Pepper, Dominique; Marais, Suzaan; Wilkinson, Robert; Bhaijee, Feriyl; Maartens, Gary; McIlleron, Helen; De Azevedo, Virginia; Cox, Helen; McDermid, Cheryl; Sokhela, Simiso; Patel, Janisha; Meintjes, GraemeBACKGROUND:HIV-1 and Mycobacterium tuberculosis cause substantial morbidity and mortality. Despite the availability of antiretroviral and antituberculosis treatment in Africa, clinical deterioration during antituberculosis treatment remains a frequent reason for hospital admission. We therefore determined the incidence, causes and risk factors for clinical deterioration. METHODS: Prospective cohort study of 292 adults who initiated antituberculosis treatment during a 3-month period. We evaluated those with clinical deterioration over the following 24 weeks of treatment. RESULTS: Seventy-one percent (209/292) of patients were HIV-1 infected (median CD4+: 129 cells/muL [IQR:62-277]). At tuberculosis diagnosis, 23% (34/145) of HIV-1 infected patients qualifying for antiretroviral treatment (ART) were receiving ART; 6 months later, 75% (109/145) had received ART. Within 24 weeks of initiating antituberculosis treatment, 40% (117/292) of patients experienced clinical deterioration due to co-morbid illness (n = 70), tuberculosis related illness (n = 47), non AIDS-defining HIV-1 related infection (n = 25) and AIDS-defining illness (n = 21). Using HIV-1 uninfected patients as the referent group, HIV-1 infected patients had an increasing risk of clinical deterioration as CD4+ counts decreased [CD4+>350 cells/muL: RR = 1.4, 95% CI = 0.7-2.9; CD4+:200-350 cells/muL: RR = 2.0, 95% CI = 1.1-3.6; CD4+<200 cells/muL: RR = 3.0, 95% CI = 1.9-4.7]. During follow-up, 26% (30/117) of patients with clinical deterioration required hospital admission and 15% (17/117) died. Fifteen deaths were in HIV-1 infected patients with a CD4+<200 cells/muL. CONCLUSIONS: In multivariate analysis, HIV-1 infection and a low CD4+ count at tuberculosis diagnosis were significant risk factors for clinical deterioration and death. The initiation of ART at a CD4+ count of <350 cells/muL will likely reduce the high burden of clinical deterioration.
- ItemOpen AccessComplications of antiretroviral therapy initiation in hospitalised patients with HIV-associated tuberculosis(Public Library of Science, 2013) van der Plas, Helen; Meintjes, Graeme; Schutz, Charlotte; Goliath, Rene; Myer, Landon; Baatjie, Dorothea; Wilkinson, Robert J; Maartens, Gary; Mendelson, MarcBACKGROUND: HIV-associated tuberculosis is a common coinfection in Sub-Saharan Africa, which causes high morbidity and mortality. A sub-set of HIV-associated tuberculosis patients require prolonged hospital admission, during which antiretroviral therapy initiation may be required. The aim of this study was to document the causes of clinical deterioration of hospitalised patients with HIV-associated tuberculosis starting antiretroviral therapy in order to inform healthcare practice in low- to middle-income countries. METHODS: Prospective, observational cohort study of adult inpatients with HIV-associated tuberculosis starting antiretroviral therapy in a dedicated tuberculosis hospital in Cape Town, South Africa. Causes of clinical deterioration and outcome were recorded in the first 12 weeks of antiretroviral therapy. Patients with rifampicin-resistant tuberculosis were excluded. RESULTS: Between May 2009 and November 2010, 112 patients (60% female), with a median age of 32 years were enrolled. At baseline the median CD4 count was 55 cells/mm 3 (IQR 31-106) and HIV viral load 5.6 log copies/mL. All patients had significant comorbidity: 82% were bed-bound, 65% had disseminated tuberculosis and 27% had central nervous system tuberculosis. Seventy six patients (68%) developed 144 clinical events after starting antiretroviral therapy. TB-IRIS, hospital-acquired infections and significant drug toxicities occurred in 42%, 20.5% and 15% of patients respectively. A new opportunistic disease occurred in 15% of patients and a thromboembolic event in 8%. Mortality during the 12 week period was 10.6%. CONCLUSIONS: High rates of TB-IRIS, hospital-acquired infections and drug toxicities complicate the course of patients with HIV-associated tuberculosis starting antiretroviral therapy in hospital. Despite the high morbidity, mortality was relatively low. Careful clinical management and adequate resources are needed in hospitalised HIV-TB patients in the 1 st three months following ART initiation.
- ItemOpen AccessCorrection to: AMBIsome Therapy Induction OptimisatioN (AMBITION): High Dose AmBisome for Cryptococcal Meningitis Induction Therapy in sub-Saharan Africa: Study Protocol for a Phase 3 Randomised Controlled Non-Inferiority Trial(2019-01-14) Lawrence, David S; Youssouf, Nabila; Molloy, SÃle F; Alanio, Alexandre; Alufandika, Melanie; Boulware, David R; Boyer-Chammard, Timothée; Chen, Tao; Dromer, Francoise; Hlupeni, Admire; Hope, William; Hosseinipour, Mina C; Kanyama, Cecilia; Lortholary, Oliver; Loyse, Angela; Meya, David B; Mosepele, Mosepele; Muzoora, Conrad; Mwandumba, Henry C; Ndhlovu, Chiratidzo E; Niessen, Louis; Schutz, Charlotte; Stott, Katharine E; Wang, Duolao; Lalloo, David G; Meintjes, Graeme; Jaffar, Shabbar; Harrison, Thomas S; Jarvis, Joseph NFollowing publication of the original article [1], we have been notified that one of the author names was listed incorrectly. Both incorrect and correct author names are presented below. The original publication has been corrected.
- ItemOpen AccessCost effectiveness of cryptococcal antigen screening as a strategy to prevent HIV-associated cryptococcal meningitis in South Africa(Public Library of Science, 2013) Jarvis, Joseph N; Harrison, Thomas S; Lawn, Stephen D; Meintjes, Graeme; Wood, Robin; Cleary, SusanObjectives Cryptococcal meningitis (CM)-related mortality may be prevented by screening patients for sub-clinical cryptococcal antigenaemia (CRAG) at antiretroviral-therapy (ART) initiation and pre-emptively treating those testing positive. Prior to programmatic implementation in South Africa we performed a cost-effectiveness analysis of alternative preventive strategies for CM. Design Cost-effectiveness analysis. METHODS: Using South African data we modelled the cost-effectiveness of four strategies for patients with CD4 cell-counts <100 cells/µl starting ART 1) no screening or prophylaxis (standard of care), 2) universal primary fluconazole prophylaxis, 3) CRAG screening with fluconazole treatment if antigen-positive, 4) CRAG screening with lumbar puncture if antigen-positive and either amphotericin-B for those with CNS disease or fluconazole for those without. Analysis was limited to the first year of ART. RESULTS: The least costly strategy was CRAG screening followed by high-dose fluconazole treatment of all CRAG-positive individuals. This strategy dominated the standard of care at CRAG prevalence ≥0.6%. Although CRAG screening followed by lumbar puncture in all antigen-positive individuals was the most effective strategy clinically, the incremental benefit of LPs and amphotericin therapy for those with CNS disease was small and additional costs were large (US$158 versus US$51per person year; incremental cost effectiveness ratio(ICER) US$889,267 per life year gained). Both CRAG screening strategies are less costly and more clinically effective than current practice. Primary prophylaxis is more effective than current practice, but relatively cost-ineffective (ICER US$20,495). CONCLUSIONS: CRAG screening would be a cost-effective strategy to prevent CM-related mortality among patients initiating ART in South Africa. These findings provide further justification for programmatic implementation of CRAG screening.
- ItemRestrictedCryptococcal immune reconstitution inflammatory syndrome presenting with erosive bone lesions, arthritis and subcutaneous abscesses(2009) Burton, Rosie; Gogela, Neliswa; Rebe, Kevin; McNally, Matt; Meintjes, GraemeA 35-year-old South African man was diagnosed with pulmonary tuberculosis (TB) in August 2007 and started on a 6-month course of treatment (intensive phase of rifampicin, isoniazid, ethambutol and pyrazinamide for 2 months, followed by continuation phase of rifampicin and isoniazid for 4 months). His TB symptoms responded rapidly. At the time of TB diagnosis, he tested HIV positive. His CD4 cell count was 12 cells/µl with a viral load of more than 500 000 copies/ml. He commenced antiretroviral therapy (ART) 6 weeks later (stavudine, lamivudine and efavirenz). After 16 weeks on ART, his CD4 cell count was 62 cells/µl with an HIV viral load of less than 50 copies/ml. Five months after starting ART and having recently completed his TB treatment, he presented to his local clinic with pain and swelling of the left hypothenar eminence. He was referred to the specialist Hand Clinic, and incision and drainage was performed. Ten days later, this was repeated due to recurrence of symptoms. He experienced no further problems, and remained compliant on ART. Six months later, he presented to our hospital for the first time with tender red subcutaneous abscesses over his sternal notch (Fig. 1a) and in his left flank. His left elbow was swollen, red and extremely painful, with a severely restricted range of movement. A radiograph of the left elbow showed a lytic lesion in the posterior periarticular aspect of the humerus and erosion of the proximal end of the radius with loss of joint space (Fig. 1b). A chest radiograph showed a pulmonary infiltrate in the base of the left lung and erosive lesions in the left 5th and 6th ribs on the lateral film (Fig. 1c). Six weeks prior to this presentation, his CD4 cell count had been 81 cells/µl, and viral load less than 50 copies/ml.
- ItemOpen AccessDiagnosis, treatment and determinants of mortality in patients hospitalized with HIV-associated tuberculosis(2021) Schutz,Charlotte; Meintjes, Graeme; Wilkinson, Robert J; Shey, MukiBackground: HIV-associated tuberculosis (HIV-TB) comprises 9% of global tuberculosis cases but contributes a disproportionate 17% of tuberculosis deaths. Tuberculosis is the leading cause of death, hospitalization and in-hospital death in HIV-positive patients world-wide with case fatality rates in hospitalized patients ranging between 13% and 32%. Underlying causes of mortality remain poorly characterized and better characterization of causes could inform development of novel management strategies to improve survival. This study aimed to assess determinants of mortality in hospitalized HIV-TB patients. I assessed the association of clinical, microbiologic and treatment factors, host soluble inflammatory mediators, markers of tuberculosis dissemination, antituberculosis drug concentrations and markers of microbial translocation with 12-week mortality in hospitalized HIV-TB patients. Methods: We conducted a prospective observational cohort study and enrolled adult HIV-positive patients hospitalized with a new diagnosis of HIV-TB in Khayelitsha Hospital in Cape Town between 2014-2016. Detailed tuberculosis diagnostic testing was performed (including urine Xpert testing) and we collected clinical samples for analysis at baseline. We performed intensive pharmacokinetic studies in a subset of patients on the third day of antituberculosis therapy. Patients were followed up for 12 weeks to ascertain vital status. Results: We enrolled 682 participants and included 576 patients with tuberculosis in the cohort analyses. Twelve-week mortality was 124/576 (21.5%) with 46/124 (37.1%) deaths occurring within 7 days of enrolment. Determinants of mortality included tuberculosis dissemination, rifampicin resistance and having features of sepsis syndrome. Using principal components analysis, we characterised an innate immune profile which was associated with mortality and with biomarkers of disseminated tuberculosis. A large proportion of patients had sub-optimal concentrations of rifampicin and isoniazid. Patients who presented with elevated lactate concentrations had higher rifampicin concentration and exposure. Opportunistic infections other than tuberculosis and microbial translocation did not have a significant association with mortality. Conclusions: There was high early mortality in hospitalized HIV-TB patients. An innate immune profile was associated with tuberculosis dissemination and mortality. Rifampicin and isoniazid concentrations and exposure were sub-optimal. These findings provide novel pathophysiologic insight and provide rationale to test high dose rifampicin and immune modulatory therapy for safety and efficacy to improve survival in this patient population.
- ItemOpen AccessDiagnosis, treatment and immunopathogenesis of the HIV-associated tuberculosis immune reconstitution inflammatory syndrome(2011) Meintjes, Graeme; Wilkinson, Robert J; Maartens, GaryThe paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is a frequent complication of antiretroviral therapy (ART) among patients who start ART while on treatment for tuberculosis (TB). The condition manifests with new, worsening or recurrent inflammatory features of TB due to immunopathology attendant on rapidly recovering immune function.
- ItemOpen AccessDifferential proteomic profiling towards elucidation of TB-IRIS pathogenesis(2022) Peyper, Janique Michelle; Blackburn, Jonathan; Meintjes, GraemeBackground Up to 59% of tuberculosis (TB)/human immunodeficiency virus (HIV) co-treated patients develop paradoxical TB-associated immune reconstitution inflammatory syndrome (TB-IRIS) after addition of antiretroviral (ARV) therapy to anti-tuberculous therapy (ATT). The course can be prolonged and the average mortality rate is 2% (75% for TB-IRIS involving the central nervous system (CNS)). Immune elements – including neutrophils - involved in the anti-Mycobacterium tuberculosis (Mtb) response are implicated in pathogenesis, which remains incompletely understood. Diagnosis is one of exclusion, no reliable laboratory markers exist, corticosteroid-mediated prophylaxis and therapy are only partially effective, and no treatment targets tissue damage. Disentangling cause and effect in complex disorders such as TB-IRIS requires techniques capable of interrogating complex biological systems. Neutrophils are the major circulating leukocyte population, the earliest innate system responders, and exhibit various unusual immunometabolic functional specialisations. Proteins represent the most functionally-proximal and commonly pharmacologically-targeted cellular biomolecules. Label-free high-performance liquid chromatography-coupled tandem mass spectrometry (HPLCMS/MS) is well-suited to differentially profiling the ex vivo neutrophil proteome in an unbiased manner, in order to investigate TB-IRIS predisposition and pathogenesis. Methods Applying first principles to existing human literature, the most parsimonious holistic hypothetical model regarding paradoxical TB-IRIS predisposition and pathogenesis was inferred. A clinical cohort of control (CTRL) and matched TB-IRIS case (IRIS) study participants was assembled. Demographic, clinical, and biochemical characteristics were analysed for statistically-significant differences and to identify potential risk/protective factors (relative risk (RR) with 95% confidence interval (CI)). A small group (n = 9) of TB-HIV- healthy volunteers (HVs) was also assembled. Phlebotomy occurred at two timepoints: just prior to ARV initiation (week 0) and at the typical time of IRIS manifestation (week 2). Neutrophils were isolated and lysed, proteins underwent on-filter protein trypsinisation, peptide salts and detergents were removed, and neutrophil-optimised HPLC-MS/MS was conducted. Spectra were submitted to MaxQuant for parent protein identification and quantitation. Comparisons of (a) CTRL0 and IRIS0 to HV (and resultant differences) identified class-differential impacts of partial ATT-treated coinfection (IRIS predisposition) and of (b) CTRL2 to CTRL0 and IRIS2 to IRIS0 (and resultant differences) identified class-differential impacts of ARV therapy (IRIS pathogenesis). Class-discriminating proteomic differences were visualised using principal components analysis (PCA), protein differential expression analysis was performed (including for detectable/undetectable and significantly differentiallyexpressed (SDE) proteins), and results informed differential functional profiling via gene ontology overrepresentation analysis (GO-ORA) and pathway activation state prediction. To address shortcomings of current knowledgebases and automated tools, a novel deep manual analysis approach focused on key inference-friendly proteins, convergent findings, and neutrophil-specific functional modules. Integrated findings extended the literature-derived TB-IRIS model, generating testable novel hypotheses, one of which was partially validated using live-cell fluorescence microscopy. Proteomic data were additionally analysed to detect Mtb proteins, preliminarily analyse variable post-translational modifications (PTMs) of interest, and identify candidate prognostic and diagnostic biomarkers. Finally, mechanistic hypotheses facilitated identification of novel potential prophylactic and therapeutic targets. Results (1) Literature suggests advanced TB/HIV-coinfection (including a higher Mtb/antigen load) as the major TB-IRIS risk factor. Attendant significant immunometabolic state perturbations include myeloid overactivation, metabolic stress (possibly including adaptogen depletion), a lack of regulatory receptors, impaired pro-inflammatory signal transduction, and impaired antigen clearance. These likely predispose to lytic cell death - including release of host- and pathogen-derived inflammatory/cytotoxic molecules and proteolytic enzymes - and less restrained/more abnormal inflammation as well as tissue damage, on restoration of HIV-suppressed inflammatory signalling pathways by ARV therapy. (2) Regarding the clinical cohort, a sample size of > 42 participants per characteristic-matched comparison class provides > 95% power to detect a two-fold change with 99% confidence. Cases exhibited known TB-IRIS risk factors, and largely expected white cell count (WCC), body mass index (BMI), and C-reactive protein (CRP) level changes in response to ARV therapy (e.g. WCC increase and BMI decrease). None of the few participants on alternate (efavirenz (EFV)- or tenofovir (TDF)-lacking) regimens developed TB-IRIS. Pre-ARV prednisone (or incidental antihistamine/anti-fungal) use was associated with a non-significantly decreased TB-IRIS risk. Interestingly, smoking is associated with a significant decrease in TB-IRIS risk by 60%. (3) Regarding sample processing and analysis, the average sample collection to neutrophil isolation interval was within recommended limits. Isolation yield exceeded 15 x 106 and 25 x 106 per sample in the CTRL and IRIS groups, respectively. Isolated neutrophil purity exceeded 80% in both groups; the few low-purity samples were excluded from subsequent proteomic analysis. Lysates from 5 x 106 neutrophils routinely yielded over 100μg total protein, tryptic digestion was efficient (on average < 96% missed cleavages), and equivalent peptide injection volumes yielded comparable total ion chromatogram (TIC) profiles and intensities. An average 23% spectral identification rate resulted in a total of 2532 protein group identifications, the deepest neutrophil proteome coverage achieved to date without pre-fractionation, representing ~12% of human protein coding genes, and ~25% of the detectable human proteome. Samples were analysed in two (randomised) batches, producing independent datasets A (N = 37) and B (N =74). Withindataset technical replicates exhibit excellent agreement in protein identities and quantities; betweendataset protein identities and functional inferences also exhibit excellent agreement. We identify a number of proteins apparently not known to be expressed by human neutrophils, as well as one predicted human protein never before observed empirically. Overall, parent pathways of level-altered proteins suggest perturbation of nine major neutrophil function modules at both time-points: (a) signal transduction, (b) pattern recognition receptor (PRR) and cytokine signalling, (c) the eicosanoid cascade, (d) neutrophil antimicrobial functions, (e) carbon-energy metabolism, (f) protein homeostasis, (g) integrated nitrogen-sulfur-B-vitamin and redox/xenobiotic/glyoxal metabolism, (h) gene expression, and (i) cytoskeletal dynamics. (4) Regarding impacts of partially ATT-treated co-infection (week 0), neutrophil proteomic profiles successfully distinguish between HV and IRIS0 or CTRL0. Many differences from HV are shared between IRIS0 and CTRL0 (i.e. driven by partially ATT-treated co-infection), but some are class-unique (i.e. driven by factors predisposing to or protecting from TB-IRIS). Findings are supported by a head-to-head comparison of the CTRL0 and IRIS0 proteomes, including changes suggesting: more prevalent type I IFN, TGFβ, and Th2-type cytokine signalling; poorer capacity for restraint of alternate complement activation; mitochondrial and oxidative stress (including proneness to necrosis); impaired function (e.g. microbicidality, TLR/IL-1R-MyD88-NFκB signalling, and caspase 1- mediated IL-1β and IL-18 maturation) of activated neutrophils; and enhanced lipid and upstream (but inhibited downstream) isoprenoid synthesis (including decreased steroidogenesis). Candidate biomarkers distinguish CTRL- and IRIS-class partially ATT-treated neutrophils from HV neutrophils and from each other. (5) Regarding impacts of ARV therapy (week 2), both IRIS and CTRL neutrophil proteomes exhibit significant changes in response to ARV therapy. Many changes are shared between IRIS and CTRL (i.e. driven by ARV therapy and declining viral load (VL)), but some are class-unique (i.e. driven by factors preventing/contributing to TB-IRIS pathogenesis). Findings are supported by a head-to-head comparison of the CTRL2 and IRIS2 proteomes, including changes suggesting: a slower decline in type I IFN signalling; increased inflammatory cytokine (e.g. IL-6, TNFα, and IFNγ) signalling and protease (e.g. MMP-8) activity; decreased sensitivity to immunoregulatory glucocorticoids and vitamin A; and increased mitochondrial, endoplasmic reticulum (ER), and oxidative stress. Candidate biomarkers distinguish CTRL- and IRIS-group ARV-exposed neutrophils from baseline and from each other. (6) Livecell fluorescence microscopy of HV neutrophils suggests that in vivo-equivalent levels of EFV rapidly alter mitochondrial, lysosomal, and aggresomal architecture in a manner consistent with organelle and protein folding stress, and suggesting cell death commitment. (7) Integrated neutrophil immunometabolic changes suggested by proteomic findings support and extend the biologically compelling literature-derived model. Model highlights include more advanced baseline TB/HIV (including higher type I IFN, TGFβ, and possibly Th2-type cytokine levels), with consequent impaired myeloid-mediated Mtb antigen clearance and depletion of cellular adaptogens. The resultant abnormal immunometabolic state produces myeloid cells less able to counteract metabolic stress and primed for less-restrained inflammation. Introduction of mitotoxic ARV drugs and rapid lifting of HIVmediated immune embargoes escalates myeloid metabolic (including oxidative) stress and overactivation (including via NLRC4, CASP4/5, TLR/IL-1R-MyD88-NFκB, and MAPK-AP1 signalling), producing - instead of Mtb clearance - inflammatory cell death with release of immune-activating and tissue-damaging host- and Mtb-derived molecules. Reactivation of Mtb lymphocyte memory responses likely only produces clinically-apparent inflammation (TB-IRIS) when multiple simultaneous but incompatible immune programmes (e.g. overzealous myeloid activity, Th1, Th2, Th17, and Treg) coexist. Based on this model, existing compounds with the potential for rational, safe, effective TB-IRIS prophylaxis/therapy are identified (e.g. glutathione, vitamins B-complex and A/D/E, rapamycin, and metformin) which may assist in restoring system homeostasis.
- ItemOpen AccessEarly severe morbidity and resource utilization in South African adults on antiretroviral therapy(BioMed Central Ltd, 2009) de Cherif, Teresa; Schoeman, Jan; Cleary, Susan; Meintjes, Graeme; Rebe, Kevin; Maartens, GaryBACKGROUND:High rates of mortality and morbidity have been described in sub-Saharan African patients within the first few months of starting highly active antiretroviral therapy (HAART). There is limited data on the causes of early morbidity on HAART and the associated resource utilization. METHODS: A cross-sectional study was conducted of medical admissions at a secondary-level hospital in Cape Town, South Africa. Patients on HAART were identified from a register and HIV-infected patients not on HAART were matched by gender, month of admission, and age group to correspond with the first admission of each case. Primary reasons for admission were determined by chart review. Direct health care costs were determined from the provider's perspective. RESULTS: There were 53 in the HAART group with 70 admissions and 53 in the no-HAART group with 60 admissions. The median duration of HAART was 1 month (interquartile range 1-3 months). Median baseline CD4 count in the HAART group was 57 x 106 cells/L (IQR 15-115). The primary reasons for admission in the HAART group were more likely to be due to adverse drug reactions and less likely to be due to AIDS events than the no-HAART group (34% versus 7%; p < 0.001 and 39% versus 63%; p = 0.005 respectively). Immune reconstitution inflammatory syndrome was the primary reason for admission in 10% of the HAART group. Lengths of hospital stay per admission and inpatient survival were not significantly different between the two groups. Five of the 15 deaths in the HAART group were due to IRIS or adverse drug reactions. Median costs per admission of diagnostic and therapeutic services (laboratory investigations, radiology, intravenous fluids and blood, and non-ART medications) were higher in the HAART group compared with the no-HAART group (US$190 versus US$111; p = 0.001), but the more expensive non-curative costs (overhead, capital, and clinical staff) were not significantly different (US$1199 versus US$1128; p = 0.525). CONCLUSIONS: Causes of early morbidity are different and more complex in HIV-infected patients on HAART. This results in greater resource utilization of diagnostic and therapeutic services.