Browsing by Subject "Immune suppression"

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    Open Access
    Can point-of-care urine LAM strip testing for tuberculosis add value to clinical decision making in hospitalised HIV-infected persons
    (Public Library of Science, 2013) Peter, Jonathan G; Theron, Grant; Dheda, Keertan
    BACKGROUND: The urine lipoarabinomannan (LAM) strip-test (Determine®-TB) can rapidly rule-in TB in HIV-infected persons with advanced immunosuppression. However, given high rates of empiric treatment amongst hospitalised patients in high-burden settings (∼50%) it is unclear whether LAM can add any value to clinical decision making, or identify a subset of patients with unfavourable outcomes that would otherwise have been missed by empiric treatment. METHODS: 281 HIV-infected hospitalised patients with suspected TB received urine LAM strip testing, and were categorised as definite (culture-positive), probable-, or non-TB. Both the proportion and morbidity of TB cases identified by LAM testing, early empiric treatment (initiated prior to test result availability) and a set of clinical predictors were compared across groups. RESULTS: 187/281 patients had either definite- (n = 116) or probable-TB (n = 71). As a rule-in test for definite and probable-TB, LAM identified a similar proportion of TB cases compared to early empiric treatment (85/187 vs. 93/187, p = 0.4), but a greater proportion than classified by a set of clinical predictors alone (19/187; p<0.001). Thirty-nine of the 187 (21%) LAM-positive patients who had either definite- or probable-TB were missed by early empiric treatment, and of these 25/39 (64%) would also have been missed by smear microscopy. Thus, 25/187 (8%) of definite- or probable-TB patients with otherwise delayed initiation of TB treatment could be detected by the LAM strip test. LAM-positive patients missed by early empiric treatment had a lower median CD4 count (p = 0.008), a higher median illness severity score (p = 0.001) and increased urea levels (p = 0.002) compared to LAM-negative patients given early empiric treatment. CONCLUSIONS: LAM strip testing outperformed TB diagnosis based on clinical criteria but in day-to-day practice identified a similar proportion of patients compared to early empiric treatment. However, compared to empiric treatment, LAM identified a different subset of patients with more advanced immunosuppression and greater disease severity.
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    Open Access
    The diagnostic accuracy of urine-based Xpert MTB/RIF in HIV-infected hospitalized patients who are smear-negative or sputum scarce
    (Public Library of Science, 2012) Peter, Jonathan G; Theron, Grant; Muchinga, Tapuwa E; Govender, Ureshnie; Dheda, Keertan
    BACKGROUND: Hospitals in sub-Saharan Africa are inundated with HIV-infected patients and tuberculosis (TB) is the commonest opportunistic infection in this sub-group. Up to one third of TB-HIV co-infected patients fail to produce a sputum sample (sputum scarce) and diagnosis is thus often delayed or missed. We investigated the sensitivity of urine-based methods (Xpert MTB/RIF, LAM strip test and LAM ELISA) in such patients. METHODOLOGY/PRINCIPAL FINDINGS: 281 HIV-infected hospitalised patients with clinically suspected TB provided a spot urine sample. The reference standard was culture positivity for Mycobacterium tuberculosis on ≥1 sputum or extra-pulmonary sample. MTB/RIF was performed using 1 ml of both unprocessed and, when possible, concentrated urine. Each unconcentrated urine sample was also tested using the Clearview LAM ELISA and Alere LAM strip test. 42% (116/242) of patients had culture-proven TB. 18% (20/54) were sputum scarce. In sputum-scarce patients, the sensitivity of urine MTB/RIF and LAM ELISA was 40% (95%CI: 22-61) and 60% (95%CI: 39-78), respectively. Urine MTB/RIF specificity was 98% (95%CI: 95-100). Combined sensitivity of urine LAM ELISA and MTB/RIF was better than MTB/RIF alone [MTB/RIF and LAM: 70% (95%CI: 48-85) vs. MTB/RIF: 40% (95%CI: 22-61), p = 0.03]. Significant predictors of urine MTB/RIF positivity were CD4<50 cells/ml (p = 0.001), elevated protein-to-creatinine ratio (p<0.001) and LAM ELISA positivity (p<0.001). Urine centrifugation and pelleting significantly increased the sensitivity of MTB/RIF over unprocessed urine in paired samples [42% (95%CI: 26-58) vs. 8% (95%CI: 0-16), p<0.001]. Urine MTB/RIF-generated C T values correlated poorly with markers of bacillary burden (smear grade and time-to-positivity). Conclusions/Significance This preliminary study indicates that urine-based MTB/RIF, alone or in combination with LAM antigen detection, may potentially aid the diagnosis of TB in HIV-infected patients with advanced immunosuppression when sputum-based diagnosis is not possible. Concentration of urine prior to MTB/RIF-testing significantly improves sensitivity.
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    Open Access
    Differential haemoparasite intensity between black sparrowhawk (Accipiter melanoleucus) morphs suggests an adaptive function for polymorphism
    (Public Library of Science, 2013) Lei, Bonnie; Amar, Arjun; Koeslag, Ann; Gous, Tertius A; Tate, Gareth J
    Recent research suggests that genes coding for melanin based colouration may have pleiotropic properties, in particular conveying raised immune function. Thus adaptive function of polymorphism may be associated with parasite resistance. The black sparrowhawk Accipiter melanoleucus is a polymorphic raptor with two morphs. Over most of its range the light morph is commonest, however within the recently colonised Western Cape of South Africa the dark morph predominates. The species breeds in winter throughout South Africa, however unlike in the rest of the species' South African range, the Western Cape experiences a winter rainfall regime, where arthropod vectors which transmit haematozoan parasites may be more abundant. We hypothesise that the higher frequency of dark morph birds in this region may be due to their improved parasite resistance, which enables them to cope with higher parasite pressure. If so, we predict that dark morph black sparrowhawks would have lower parasite burdens than light morph birds. Within our population the prevalence of the two most common haematozoan parasites was high, with 72% of adults infected with Haemoproteus nisi and 59% of adults infected with Leucocytozoon toddi . We found no difference in prevalence for either parasite between adult morphs, or between chicks of different parental morphs. However, within adults infected with H. nisi , infection intensity was significantly higher in light morphs than dark morphs. This suggests that dark morphs have lower parasite loads than light morphs due to resistance rather than morph-specific habitat exploitation. Greater resistance to Haemoproteus parasites may therefore be one of the mechanisms through which dark morph black sparrowhawks have a selective advantage in this region and may explain why they are most common in our study area. In other regions, the cost to benefit ratio may be in favour of the light morph, where parasites are less abundant or virulent.