Nuevas herramientas para la detección de la tuberculosis latente.

Tuberculosis is a serious public health problem worldwide, particularly in developing countries. In Colombia, the focus is on the clinical management of patients with active disease, but not on preventive programs that identify and treat individuals with a latent tuberculosis infection. This review emphasized the importance of preventative programs and their critical role in the curtailment of infection dissemination in the community. An effective program includes chemoprophylactic treatment of household contacts and detection of individuals with latent tuberculosis infection and with high risk of reactivation of disease. The tuberculin skin test has been used effectively for more than 100 years, despite inherent sensitivity and specificity limitations. Herein the advances provided by a new generation of immunoassays are reviewed, includingthe commercially-available Quantiferon and the experimental development of ELISPOT. Both are based on the detection of IFNgamma secretion by peripheral T cells upon incubation with Mycobacterium tuberculosis antigens. Finally, the importance of molecular techniques aimed at detecting DNA from the mycobacterium is discussed as a possible complement to the described immunoassays.La tuberculosis es un problema serio de salud pública en el mundo, especialmente en países en vía de desarrollo, inclusive Colombia. En nuestro país estamos enfocados en el manejo clínico de los pacientes con tuberculosis activa, pero no hay campañas efectivas que identifiquen y provean terapia a los individuos con las formas latentes de la infección y con alto riesgo de progresar hacia la enfermedad. En esta revisión se plantea la importancia de realizar dichas campañas para evitar la diseminación de la infección en la comunidad. Esto incluye la búsqueda activa y el tratamiento profiláctico de los contactos de casos recientes, así como la de individuos con tuberculosis latente con alto riesgo de desarrollar la enfermedad. En ausencia de una prueba de oro para detectar la tuberculosis latente, la prueba cutánea de la tuberculina se ha utilizado por más de 100 años para dicho fin, a pesar de sus limitaciones de sensibilidad y especificidad. En esta revisión se evalúan las ventajas y desventajas de una nueva generación de inmunoensayos que incluye la prueba comercial Quantiferon y el desarrollo experimental del ELISPOT. Ambas se basan en la detección de IFN? secretado por linfocitos de sangre periférica cuando se incuban con antígenos específicos del bacilo tuberculoso. Finalmente, se plantea la importancia de desarrollar pruebas moleculares enfocadas en detectar el ADN de la micobacteria como posible complemento a los inmunoensayos descritos

Hyperglycemia and dyslipidemia: Reduced HLA-DR expression in monocyte subpopulations from diabetes patients

Immune dysfunction contributes to the higher risk of communicable and non-communicable diseases among diabetics. HLA-DR expression is a robust marker of immune competence in mononuclear cells, including antigen presentation to CD4 lymphocytes. Given the high prevalence of obesity among diabetics, we evaluated the independent association between hyperglycemia and dyslipidemias with respect to HLA-DR expression in blood monocytes from type 2 diabetes patients. The monocytes from individuals with (n=16) or without diabetes (n=25) were phenotyped by flow cytometry to assess the differential expression of HLA-DR on their three subpopulations (classical, intermediate and non-classical monocytes). Diabetes was independently associated with lower HLA-DR expression across all monocyte subpopulations (p \u3c0.05). Blood triglycerides were associated with further HLA-DR depression (interaction p \u3c0.002). Cholesterols counterbalanced the reductive effect, with CD36, a receptor for oxidized cholesterol, correlating with HLA-DR (rho=0.373; p= 0.016). Future studies are warranted to elucidate the complex interactions between hyperglycemia and dyslipidemias on antigen presentation in diabetic monocytes

The re-emerging association between tuberculosis and diabetes: lessons from past centuries

The association between tuberculosis (TB) and diabetes mellitus (DM) had a common place in the literature up to the first half of the 20th century, but virtually disappeared with the discovery of insulin to treat DM and antibiotics to cure TB. In the late 1990s the literature began to re-emerge with the worldwide increase in type 2 DM, particularly in TB-endemic countries. Today, type 2 DM is the most prevalent comorbidity among TB patients and the World Health Organization considers it a threat to TB control. We summarize the literature on TB and DM up to the 1960s. Then we evaluate unique aspects of this comorbidity in older times, such as the frequent diabetic comas that suggest challenges for proper DM management as insulin was being implemented, or the absence of antibiotics to cure TB. Despite the unique aspects of each study period, the literature across times is consistent in key aspects of the association. Namely, a higher TB prevalence among DM (versus non-DM patients), the importance of glucose control and chronic DM on TB susceptibility and the higher risk of death among patients with the comorbidity. From the older literature, we can infer the likely contribution of type 1 DM to TB (in addition to type 2), regardless of their differing autoimmune or metabolic pathophysiology, respectively. Furthermore, in the older literature there was a notable reporting of DM development among TB patients, even though DM usually preceded TB. This observation deserves further epidemiological and basic studies to elucidate this intriguing aspect of the relationship between TB and DM

High all-cause mortality and increasing proportion of older adults with tuberculosis in Texas, 2008–2020

Pulmonary tuberculosis (PTB) elimination efforts must consider the global growth of the ageing population. Here we used TB surveillance data from Texas, United States (2008–2020; total n = 10656) to identify unique characteristics and outcomes in older adults (OA, ≥65 years) with PTB, compared to young adults (YA, 18–39 years) or middle-aged adults (40–64 years). We found that the proportion of OA with PTB increased from 15% in 2008 to 24% in 2020 (trend p \u3c 0.05). Diabetes was highly prevalent in OA (32%) but not associated with adverse outcomes. Death was 13-fold higher in OA compared to YA and was 7% at the time of diagnosis which suggests diagnostic delays. However, once TB was suspected, we found no differences in culture, smear, or nucleic acid detection of mycobacteria (although less lung cavitations) in OA. During treatment, OA had less drug-resistant TB, few adverse reactions and adhered with TB treatment. We recommend training healthcare workers to ‘think TB’ in OA, for prompt treatment initiation to diminish deaths. Furthermore, OA should be added as a priority group to the latent TB treatment guidelines by the World Health Organization, to prevent TB disease in this highly vulnerable group

Pulmonary Tuberculosis in Older Adults, Texas, 2008 - 2020: Trends and adverse outcomes

Background: After two decades of 2% annual declines in the global incidence of TB, there was a 3.6% increase between 2020 and 2021. The World Health Organization’s (WHO) ‘End TB Strategy’ is aimed at reducing TB incidence by 80% and TB deaths by 90% by 2030, compared with 2015, but its goals will not be reached at the current pace. Reacceleration of TB elimination efforts must take into consideration the changing epidemiology of TB, including an aging global population. The older adult population, aged 65 and older, is growing faster than all other age groups, and in the United States, they will outnumber children under the age of 18 for the first time by 2034. Older adults have the highest prevalence of latent TB and are prone to immune-suppressive conditions that predispose them to reactivation or new TB infection. In this study, we aimed to examine sociodemographics and clinical findings unique to older patients, when compared to younger adults, with pulmonary TB (PTB) and identify risk factors that predict adverse PTB outcomes in this age group. Methods: Pulmonary TB surveillance data from Texas, 2008 – 2020 (n=10,656), was evaluated for patient characteristics, outcomes, and trends in older (OA, ≥65 y.) vs. young (YA, 18 to 39 y.) or middle-aged (MAA, 40 to 64 y.) adults. Multivariable logistic regression models were used to identify risk factors for treatment noncompletion and all-cause death. Results: The OA group grew from 15% in 2008 to 24% in 2020 with the proportion of OA patients born in a country other than the U.S. or Mexico, also increasing during the surveillance period, trend P \u3c .001. Long-term care facility residence, diabetes, and dead at diagnosis increased with age (P for trend \u3c .001 for each) while cavities on chest x-ray and performing TB infection tests, tuberculin skin test (TST) or interferon-gamma release assays (IGRAs), decreased with age (P for trend \u3c .001 for each). Older age was not associated with failure to complete TB treatment. However, birth in a country other than the U.S. or Mexico (aOR 2.27, 95% CI 1.27, 4.08) and homeless (aOR 4.33, 95% CI 1.63, 11.53) were associated with treatment noncompletion in the OA. The odds of death during TB treatment doubled for OA patients with an MTB positive culture (aOR 2.31, 95% CI 1.55, 3.44), while birth in Mexico (aOR 0.74, 95% CI 0.56, 0.99) or other country other than the U.S. or Mexico (aOR 0.48, 95% CI 0.33, 0.68) was protective against death. Conclusion: In Texas, there has been an increase in the proportion of older adults with TB over the past decade and this age group is at higher risk of all-cause mortality. We recommend including older adults as a priority group in latent TB treatment guidelines to prevent the development of TB in this highly-vulnerable age group

The Impact of Aging on the Lung Alveolar Environment, Predetermining Susceptibility to Respiratory Infections

Respiratory infections are one of the top causes of death in the elderly population, displaying susceptibility factors with increasing age that are potentially amenable to interventions. We posit that with increasing age there are predictable tissue-specific changes that prevent the immune system from working effectively in the lung. This mini-review highlights recent evidence for altered local tissue environment factors as we age focusing on increased tissue oxidative stress with associated immune cell changes, likely driven by the byproducts of age-associated inflammatory disease. Potential intervention points are presented

Antibody Fc Glycosylation Discriminates Between Latent and Active Tuberculosis

Background. Mycobacterium tuberculosis remains a global health problem and clinical management is complicated by difficulty in discriminating between latent infection and active disease. While M. tuberculosis-reactive antibody levels are heterogeneous, studies suggest that levels of IgG glycosylation differ between disease states. Here we extend this observation across antibody domains and M. tuberculosis specificities to define changes with the greatest resolving power. Methods. Capillary electrophoretic glycan analysis was performed on bulk non-antigen–specific IgG, bulk Fc domain, bulk Fab domain, and purified protein derivative (PPD)- and Ag85A-specific IgG from subjects with latent (n = 10) and active (n = 20) tuberculosis. PPD-specific isotype/subclass, PPD-specific antibody-dependent phagocytosis, cellular cytotoxicity, and natural killer cell activation were assessed. Discriminatory potentials of antibody features were evaluated individually and by multivariate analysis. Results. Parallel profiling of whole, Fc, and Fab domain-specific IgG glycosylation pointed to enhanced differential glycosylation on the Fc domain. Differential glycosylation was observed across antigen-specific antibody populations. Multivariate modeling highlighted Fc domain glycan species as the top discriminatory features, with combined PPD IgG titers and Fc domain glycans providing the highest classification accuracy. Conclusions. Differential glycosylation occurs preferentially on the Fc domain, providing significant discriminatory power between different states of M. tuberculosis infection and disease

Tuberculosis presentation and outcomes in older Hispanic adults from Tamaulipas, Mexico

Older people are at high risk of developing and dying from pulmonary infections like tuberculosis (TB), but there are few studies among them, particularly in Hispanics. To address these gaps, we sought to identify host factors associated with TB and adverse treatment outcomes in older Hispanics by conducting a cross-sectional study of TB surveillance data from Tamaulipas, Mexico (2006–2013; n = 8381). Multivariable logistic regressions were assessed for older adults (OA ≥65 years) when compared to young (YA, 18–39 years) and middle-aged adults (40–64 years). We found that the OA had features associated with a less complicated TB (e.g., lower prevalence of extra-pulmonary TB and less likely to abandon treatment or have drug resistant TB), and yet, were more likely to die during TB treatment (adj-OR 3.9, 95% 2.5, 5.25). Among the OA, excess alcohol use and low body mass index increased their odds of death during TB treatment, while a higher number of reported contacts (social support) was protective. Diabetes was not associated with adverse outcomes in OA. Although older age is a predictor of death during TB disease, OA are not prioritized by the World Health Organization for latent TB infection screening and treatment during contact investigations. With safer, short-course latent TB infection treatment available, we propose the inclusion of OA as a high-risk group in latent TB management guidelines

Multi-OMICs analysis reveals metabolic and epigenetic changes associated with macrophage polarization

Macrophages (MФ) are an essential immune cell for defense and repair that travel to different tissues and adapt based on local stimuli. A critical factor that may govern their polarization is the cross-talk between metabolism and epigenetics. However, simultaneous measurements of metabolites, epigenetics, and proteins (phenotype) has been a major technical challenge. To address this, we have developed a novel triomics approach using mass spectrometry to comprehensively analyze metabolites, proteins, and histone modifications, in a single sample. To demonstrate this technique, we investigated the metabolic-epigenetic-phenotype axis following polarization of human blood-derived monocytes into either \u27pro-inflammatory M1\u27- or \u27anti-inflammatory M2-\u27 MФs. We report here a complex relationship between arginine, tryptophan, glucose, and the citric acid cycle (TCA) metabolism, protein and histone post-translational modifications, and human macrophage polarization that was previously not described. Surprisingly, M1-MФs had globally reduced histone acetylation levels but high levels of acetylated amino acids. This suggests acetyl-CoA was diverted, in part, towards acetylated amino acids. Consistent with this, stable isotope tracing of glucose revealed reduced usage of acetyl-CoA for histone acetylation in M1-MФs. Furthermore, isotope tracing also revealed MФs uncoupled glycolysis from the TCA cycle, as evidenced by poor isotope enrichment of succinate. M2-MФs had high levels of kynurenine and serotonin which are reported to have immune-suppressive effects. Kynurenine is upstream of de novo NAD+ metabolism which is a necessary cofactor for Sirtuin-type histone deacetylases. Taken together, we demonstrate a complex interplay between metabolism and epigenetics that may ultimately influence cell phenotype

Human Macrophages Exhibit GM-CSF Dependent Restriction of Mycobacterium tuberculosis Infection via Regulating Their Self-Survival, Differentiation and Metabolism

GM-CSF is an important cytokine that regulates the proliferation of monocytes/macrophages and its various functions during health and disease. Although growing evidences support the notion that GM-CSF could play a major role in immunity against tuberculosis (TB) infection, the mechanism of GM-CSF mediated protective effect against TB remains largely unknown. Here in this study we examined the secreted levels of GM-CSF by human macrophages from different donors along with the GM-CSF dependent cellular processes that are critical for control of M. tuberculosis infection. While macrophage of different donors varied in their ability to produce GM-CSF, a significant correlation was observed between secreted levels of GM-CSF, survial of macrophages and intra-macrophage control of Mycobacterium tuberculosis bacilli. GM-CSF levels secreted by macrophages negatively correlated with the intra-macrophage M. tuberculosis burden, survival of infected host macrophages positively correlated with their GM-CSF levels. GM-CSF-dependent prolonged survival of human macrophages also correlated with significantly decreased bacterial burden and increased expression of self-renewal/cell-survival associated genes such as BCL-2 and HSP27. Antibody-mediated depletion of GM-CSF in macrophages resulted in induction of significantly elevated levels of apoptotic/necrotic cell death and a simultaneous decrease in autophagic flux. Additionally, protective macrophages against M. tuberculosis that produced more GM-CSF, induced a stronger granulomatous response and produced significantly increased levels of IL-1β, IL-12 and IL-10 and decreased levels of TNF-α and IL-6. In parallel, macrophages isolated from the peripheral blood of active TB patients exhibited reduced capacity to control the intracellular growth of M. tuberculosis and produced significantly lower levels of GM-CSF. Remarkably, as compared to healthy controls, macrophages of active TB patients exhibited significantly altered metabolic state correlating with their GM-CSF secretion levels. Altogether, these results suggest that relative levels of GM-CSF produced by human macrophages plays a critical role in preventing cell death and maintaining a protective differentiation and metabolic state of the host cell against M. tuberculosis infection