A Retrospective Cohort Analysis of Pediatric Tuberculosis in North Carolina, 1994-2002

Background: The incidence of pediatric tuberculosis (TB) in North Carolina decreased from the mid 1990s to 200l. In 2002, the number of pediatric TB cases increased from 9 in 2001 to 32 in 2002, representing more than a 250% increase. Objective: To describe the epidemiology and clinical characteristics of pediatric TB in North Carolina and identify factors contributing to the rise in tuberculosis cases among children less than 15 years of age. Methods: Retrospective review of TB surveillance data and local health department records of all reported pediatric TB cases and their source case between the years 1994 and 2002. Results: 180 cases of pediatric TB were reported from 1994-2002. The incidence of pediatric TB increased from 0.53 to 1.85 per 100,000 from 2001 to 2002. TB case rates in 2002 were higher in children less than 5 years of age (3.05 per 100,000) compared to children 5-14 years of age (1.28 per 100,000). TB case rates were 10- to 44-fold higher among minority children compared to non-Hispanic white children. Although there was no significant increase in the incidence of TB in the Hispanic pediatric population, there was a significant increase in the proportion of Hispanic children with tuberculosis (p-value =.04). Children with a foreign association accounted for an increasing proportion of pediatric TB cases over time, however, the increase was not statistically significant (p-value = 0.09). Transmission of TB to children could have been prevented in 6.75% of cases had a source case identified the child as a contact, and in 11.7% of cases had the source case completed prophylaxis for latent TB infection. TB disease may have been prevented in 7.2% of cases had the contact investigation not been delayed, 2.2% of cases had children with latent TB infection completed prophylaxis, and in 4.4% of cases had child contacts <5 years of age with a negative PPD taken or received prophylaxis. Overall, 51/180 cases (28.3%) might have been prevented had appropriate measures been taken. Conclusion: The incidence of pediatric TB increased significantly from 2001 to 2002. TB in the minority population continues to be a problem. TB in children with a foreign-association is increasing. Improvements in contact investigations and completion of prophylaxis for LTBI may reduce the incidence of pediatric TB.Master of Public Healt

Severe Infective Endocarditis Caused by Bartonella rochalimae

A 22-year-old man from Guatemala sought care for subacute endocarditis and mycotic brain aneurysm after living in good health in the United States for 15 months. Bartonella rochalimae, a recently described human and canine pathogen, was identified by plasma microbial cell-free DNA testing. The source of infection is unknown

Tuberculosis Therapy Modifies the Cytokine Profile, Maturation State, and Expression of Inhibitory Molecules on Mycobacterium tuberculosis-Specific CD4+ T-Cells.

BackgroundLittle is known about the expression of inhibitory molecules cytotoxic T-lymphocyte antigen-4 (CTLA-4) and programmed-death-1 (PD-1) on Mycobacterium tuberculosis (Mtb)-specific CD4 T-cells and how their expression is impacted by TB treatment.MethodsCryopreserved PBMCs from HIV-TB co-infected and TB mono-infected patients with untreated and treated tuberculosis (TB) disease were stimulated for six hours with PPD and stained. Using polychromatic flow cytometry, we characterized the differentiation state, cytokine profile, and inhibitory molecule expression on PPD-specific CD4 T-cells.ResultsIn our HIV-TB co-infected cohort, TB treatment increased the proportion of PPD-specific CD4 T-cells co-producing IFN-γ+IL-2+TNF-α+ and IFN-γ+IL-2+ (p = 0.0004 and p = 0.0002, respectively) while decreasing the proportion of PPD-specific CD4 T-cells co-producing IFN-γ+MIP1-β+TNF-α+ and IFN-γ+MIP1-β+. The proportion of PPD-specific CD4 T-cells expressing an effector memory phenotype decreased (63.6% vs 51.6%, p = 0.0015) while the proportion expressing a central memory phenotype increased (7.8% vs. 21.7%, p = 0.001) following TB treatment. TB treatment reduced the proportion of PPD-specific CD4 T-cells expressing CTLA-4 (72.4% vs. 44.3%, p = 0.0005) and PD-1 (34.5% vs. 29.2%, p = 0.03). Similar trends were noted in our TB mono-infected cohort.ConclusionTB treatment alters the functional profile of Mtb-specific CD4 T-cells reflecting shifts towards a less differentiated maturational profile and decreases PD-1 and CTLA-4 expression. These could serve as markers of reduced mycobacterial burden. Further study is warranted

Clinical characteristics of COVID‐19 in solid organ transplant recipients following COVID‐19 vaccination: A multicenter case series

Background Solid organ transplant recipients (SOTR) have diminished humoral immune responses to COVID‐19 vaccination and higher rates of COVID‐19 vaccine breakthrough infection than the general population. Little is known about COVID‐19 disease severity in SOTR with COVID‐19 vaccine breakthrough infections. Methods Between 4/7/21 and 6/21/21, we requested case reports via the Emerging Infections Network (EIN) listserv of SARS‐CoV‐2 infection following COVID‐19 vaccination in SOTR. Online data collection included patient demographics, dates of COVID‐19 vaccine administration, and clinical data related to COVID‐19. We performed a descriptive analysis of patient factors and evaluated variables contributing to critical disease or need for hospitalization. Results Sixty‐six cases of SARS‐CoV‐2 infection after vaccination in SOTR were collected. COVID‐19 occurred after the second vaccine dose in 52 (78.8%) cases, of which 43 (82.7%) occurred ≥14 days post‐vaccination. There were six deaths, three occurring in fully vaccinated individuals (7.0%, n = 3/43). There was no difference in the percentage of patients who recovered from COVID‐19 (70.7% vs. 72.2%, p = .90) among fully and partially vaccinated individuals. We did not identify any differences in hospitalization (60.5% vs. 55.6%, p = .72) or critical disease (20.9% vs. 33.3%, p = .30) among those who were fully versus partially vaccinated. Conclusions SOTR vaccinated against COVID‐19 can still develop severe, and even critical, COVID‐19 disease. Two doses of mRNA COVID‐19 vaccine may be insufficient to protect against severe disease and mortality in SOTR. Future studies to define correlates of protection in SOTR are needed

PD-1 and CTLA-4 expression on PPD-specific CD4 T-cells in response to TB treatment.

<p><b>A.</b> Representative plot showing the gating scheme used to identify PD-1, CTLA-4, and 2B4 expression on PPD-specific CD4 T-cells. Single, live, CD3⁺, CD4⁺ cells were gated for CD27 and CD45RO. The naïve CD4 T cell population was identified (CD27⁺CD45RO^-) and selected to set gates for PD-1, CTLA-4 and 2B4 as this population typically does not express inhibitory molecules. These gates were then applied to PPD-specific and total CD4 T-cell populations. <b>B.</b> Expression of PD-1, CTLA-4, and 2B4 on PPD-specific CD4 T-cells in untreated and treated TB disease. <b>C.</b> Correlation between baseline CD4 T-cell count and frequency of PD-1 and CTLA-4 expression on PPD-specific CD4 T-cells in untreated and treated TB disease. Lines of best fit, along with Spearman’s rank correlation coefficient and corresponding p-values are shown <b>D.</b> Expression of PD-1, CTLA-4, and 2B4 on CMV-specific CD4 T-cells in untreated and treated TB disease in our HIV-TB and TB cohorts. <b>E</b>. Expression of PD-1, CTLA-4, and 2B4 on total CD4 T-cells in untreated and treated TB disease in our HIV-TB and TB cohorts. <b>F</b>. Bar graph depicts the co-expression patterns of PD-1, CTLA-4, and 2B4 on PPD-specific CD4 T-cells in untreated and treated TB disease in our HIV-TB and TB cohorts. To assess expression of inhibitory molecules on PPD and CMV-specific CD4 T-cells, only samples with at least 50 cytokine positive cells and 2-fold higher responses than negative control samples were included to allow for a statistically valid analysis. * denotes p<0.05, ** p<0.01, *** p<0.001 by Wilcoxon matched-pairs signed rank test. $denotes p<0.05,$ $p<0.01,$ $$ p<0.001 by Mann-Whitney test.</p

Characteristics of ACTG 5221 (A5221) Study Population.

<p>Characteristics of ACTG 5221 (A5221) Study Population.</p

TB therapy alters maturation phenotype of PPD-specific CD4 T-cells.

<p><b>A.</b> Representative example of differentiation marker expression on PPD-specific CD4 T-cells. PPD-specific CD4 T-cells (red dots) are overlaid onto density plots of CD27 and CD45RO and CD27 and CD57, gated on total CD4 T-cells. <b>B.</b> Frequency of PPD-specific CD4 T-cells expressing CD27⁺CD45RO⁺ (CM), CD27^-CD45RO⁺ (EM), and CD57⁺ (TD) phenotypes. <b>C.</b> Correlation between baseline CD4 T-cell count and frequency of PPD-specific CD4 T-cells expressing CM and TD phenotypes in untreated and treated TB disease. Lines of best fit, along with Spearman’s rank correlation coefficient and corresponding p-values are shown <b>D.</b> Frequency of CMV-specific CD4 T-cells expressing CM, EM, and TD phenotypes in our HIV-TB and TB cohorts. <b>E.</b> Frequency of naïve, CM, EM, and TD subsets on total CD4 T-cells in untreated and treated TB disease in our HIV-TB and TB cohorts. To assess maturation phenotype on PPD and CMV-specific CD4 T-cells, only samples with at least 50 cytokine positive cells and 2-fold higher responses than negative control samples were included to allow for a statistically valid analysis. The Wilcoxon matched-pairs signed rank test was used for paired comparisons (HIV-TB cohort) while the Mann-Whitney test was used to analyze unpaired data (TB cohort and comparisons between cohorts). * denotes p<0.05, ** p<0.01, *** p<0.001 by Wilcoxon matched-pairs signed rank test. $denotes p<0.05,$ $p<0.01,$ $$ p<0.001 by Mann-Whitney test.</p

TB therapy alters the functional profile of PPD-specific CD4 T-cells.

<p><b>A.</b> Representative plot showing the gating scheme used to identify cytokine/chemokine positive cells. Single, live, CD3⁺, CD4⁺ T cells were gated for CD27 and CD45RO to identify the total CD4 memory population. Cytokine/chemokine gates were then applied to the total CD4 memory population to identify cytokine/chemokine positive cells. <b>B.</b> Total frequency of IFN-γ, TNF-α, IL-2, and MIP-1β produced by memory CD4 T-cells in untreated and treated TB disease within our HIV-TB and TB cohorts. Background cytokine/chemokine production from the negative control sample was subtracted. <b>C.</b> Pie graph displaying the proportion of cytokine/chemokine⁺ CD4 T-cells producing all 4 cytokines/chemokines (light grey wedge) or any combination of 3 cytokines/chemokines (medium gray), 2 cytokines/chemokines (dark grey), or a single cytokine/chemokine (black wedge) in untreated and treated TB disease. The bar graph depicts the relative contribution of each cytokine/chemokine producing subset to the overall PPD-specific CD4 T-cell response. “G” denotes IFN-γ, “2” denotes IL-2, “T” denotes TNF-α, and “M” denotes MIP-1β. For all bar graphs bars represent the interquartile range (IQR), horizontal lines denote the median, and whiskers the 10^th and 90^th percentiles. Solid bars represent our HIV-TB cohort, patterned bars represent our TB cohort. Light gray represents untreated TB disease while dark gray represents treated TB disease. Statistical analysis was performed using the Wilcoxon matched-pairs signed rank test for paired data (HIV-TB cohort) and the Mann-Whitney test for unpaired data (TB cohort or comparisons between cohorts).* denotes p<0.05, ** p<0.01, *** p<0.001 by Wilcoxon matched-pairs signed rank test. $denotes p<0.05,$ $p<0.01,$ $$ p<0.001 by Mann-Whitney test.</p