|Ahead of print publication
Cytokine response to antitubercular therapy in patients with human immunodeficiency virus and tuberculosis coinfection with respect to CD4 count and viral load − A pilot study
Nagesh Venkata Ivaturi1, VK Sashindran2, Anchit Raj Singh3, Vivek Aggarwal4
1 Military Hospital, Jabalpur, Madhya Pradesh, India
2 DY Patil School of Medicine, Nerul, Navi Mumbai, India
3 Base Hospital, Barrakpore, West Bengal, India
4 Department of Internal Medicine, Armed Forces Medical College, Pune, Maharashtra, India
|Date of Submission||06-Dec-2021|
|Date of Decision||28-Dec-2021|
|Date of Acceptance||01-Jan-2022|
|Date of Web Publication||10-Aug-2022|
Nagesh Venkata Ivaturi,
Military Hospital, Jabalpur, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Introduction and Background: Monitoring of efficacy of antitubercular treatment (ATT) in patients with human immunodeficiency virus (HIV) and tuberculosis (TB) coinfection is more often based on clinical judgment. Having an objective biomarker monitor, the treatment response to ATT is urgently required in HIV-TB coinfection. Methodology: Fifty patients of diagnosed HIV infection with TB as opportunistic infection were enrolled. Baseline CD4 and HIV viral load were done. Serum cytokine levels of IFN γ, IL-10, IL-2, and interferon gamma-inducible protein-10 (IP-10) were assessed at baseline and after 2 months of initiation of ATT. Results: Out of fifty patients, 43 (86%) were male and 7 (14%) were female. The mean age of the patients was 39 years. The median CD4 count was 342 cells/uL, and the mean plasma HIV viral load was 3,05,093 copies/ml. Sputum for AFB was positive in 15 (30%) patients. The levels of interferon-gamma (INF γ), interleukin (IL)-4, and IL-10 have shown a statistically significant decline over 2 months [Table 1] with a P = 0.005, <0.001, and 0.023, respectively. There was a significant correlation between IP-10 and CD4 count in male patients as assessed by Pearson correlation coefficient (P = 0.048). Conclusion: The levels of INF γ, IL-4, and IL-10 have shown a statistically significant decline over 2 months [Table 1] with a P = 0.005, <0.001, and 0.023, respectively. There was a significant correlation between IP-10 and CD4 count in male patients.
Keywords: Antitubercular therapy, cytokines, human immunodeficiency virus and tuberculosis coinfections
|How to cite this URL:|
Ivaturi NV, Sashindran V K, Singh AR, Aggarwal V. Cytokine response to antitubercular therapy in patients with human immunodeficiency virus and tuberculosis coinfection with respect to CD4 count and viral load − A pilot study. J Mar Med Soc [Epub ahead of print] [cited 2022 Oct 5]. Available from: https://www.marinemedicalsociety.in/preprintarticle.asp?id=353644
| Introduction|| |
Human immunodeficiency virus and tuberculosis (HIV-TB) coinfection is an important public health problem worldwide, especially in the developing countries with high burden of TB. HIV-TB coinfection has a wide spectrum of illnesses which can range from extrapulmonary, smear-positive, and smear-negative TB. TB infection in HIV can be seen at any CD4 levels and clinical presentation varies with immune status of the individual. HIV patients with high CD4 counts usually present with typical features of TB as seen in HIV-negative patients. HIV patients with low CD4 count are likely to present with disseminated TB or atypical clinical presentation.
In India, the diagnosis and management of TB are protocol based as per the Revised National TB Control Program guidelines. In smear-positive cases, the Cartridge-Based Nucleic Acid Amplification Test is a main tool to diagnose TB and screen for drug resistance. In such cases, it is possible to culture Mycobacterium TB (MTB) and performs drug-sensitivity testing. Monitoring in smear-positive and culture-positive TB patients can be done by repeating the smear after the completion of extensive phase or during the continuation phase. Management and treatment response, monitoring of patients with extrapulmonary and smear-negative TB are less well defined and mainly depends upon clinical and radiological correlation. In patients with HIV infection, extrapulmonary and smear-negative TB are more common than smear-positive TB. Monitoring of response to antitubercular treatment (ATT) will be difficult, especially in smear-negative and extrapulmonary TB patients. Thus, using a suitable biomarker can be of great benefit in monitoring the treatment response in HIV-TB coinfection.
Cytokines are being studied as a potential biomarker to monitor the response to antitubercular therapy., There is a renewed interest in finding such a biomarker which may be used in clinical practice for initiating and monitoring the response to ATT. Interferon-gamma (INF γ) produced mainly by T-lymphocytes and natural-killer cells are modulated by CD4 and dendritic cells. It represents protective response against MTB infection and is an important mediator of macrophage response to MTB. Interleukin-4 (IL-4) is produced by TH-2 response and is responsible for suppressing the TH-1 response and may be associated with disseminated forms of disease. IL-10 is also a part of the TH-2 response and is involved in the deactivation of macrophages and diminished pro-inflammatory cytokine production. Interferon gamma-induced protein (IP-10) simulates the migration and adhesion of TH-1 cells. It is considered to correlate with susceptibility to TB and as a marker for disease progression.
There is no study available on the utility of biomarkers in initiating and monitoring response of ATT in HIV-TB coinfection. This pilot study will help us to identify the utility of potential biomarkers, if any, in HIV-TB coinfection.
The aim of this study was to study the response of cytokines to antitubercular therapy in HIV-positive individuals with respect to CD4 count and viral load.
The objective of this study was to measure the levels of cytokines interferon-gamma (INF γ), IL-4, IL-10 (IL-10), and interferon gamma-inducible protein-10 before initiation of antitubercular therapy and after 2 months of antitubercular therapy.
| Methodology|| |
It was a pilot study carried out at a tertiary care center in India. Ethical clearance was taken from the Institutional Ethics Committee. Since there were no previous clinical studies on correlation between CD4, viral load, and on the serum concentrations of INF γ, IL-4, IL-10, and IP-10 cytokines in patients with HIV-TB coinfection, a sample size of fifty patients were taken as a pilot study.
All new HIV-TB coinfection patients with ages more than 18 years were enrolled in this study. Patients on long-term steroids, rheumatological disorders, chronic kidney disease, hematological malignancy, pregnancy, and other opportunistic infections were excluded from this study.
Serum cytokine levels of INF γ, IL-4, IL-10, and IP-10 were collected at the start of therapy and after 2 months of therapy observing universal safety precautions. The serum was separated and stored at -70°C till the required number of samples to run a test sequence was collected. The cytokine levels were estimated on commercially available ELISA-based kits, and all tests were performed in duplicate.
Statistical analysis was done on IBM Corp. Released 2016. IBM SPSS Statistics for Windows, Ver-sion 24.0. Armonk, NY: IBM Corp, and paired t-test was done for each cytokine before and after 2 months of ATT. Pearson's correlation coefficient was calculated to study the correlation between CD4 count and plasma viral load with each cytokine, and two-tailed P values were calculated.
| Results|| |
A total of 50 patients with HIV and TB coinfection were included in the study. Out of these, 43 (86%) were male and 7 (14%) were female. The mean age of the patients was 39 years. The median CD4 count was 342 cells/uL, and the mean plasma viral load was 3,05,093 copies/ml. Sputum for AFB was positive in 15 (30%) patients. The baseline characteristics are shown in [Table 2].
The levels of INF γ, IL-4, and IL-10 have shown a statistically significant decline over 2 months [Table 1] with a P = 0.005, <0.001, and 0.23, respectively.
There was a significant correlation between IP-10 and CD4 count in male patients as assessed by Pearson correlation coefficient (P = 0.048). However, this association between IP-10 and CD4 count could not be demonstrated in female patients (P = 0.193). There was no significant correlation between CD-4 count and IL-4, INF γ, and IL-10 [Table 3]. Viral load also did not show any significant correlation with any of the biomarkers as assessed by Pearson correlation coefficient [Table 4].
| Discussion|| |
This pilot study shows that cytokine levels of INF γ, IL-4, and IL-6 reduced with initiation of ATT in HIV-TB coinfection patients. This is especially important in HIV patients with extrapulmonary and smear-negative TB where monitoring of response to treatment is difficult. Need to find a novel biomarker to assess the response of ATT in extrapulmonary, drug-resistant TB, and pediatric TB has been emphasized in a study done by Rookwood., Studies are being done to identify a good immune biomarker which can be utilized in diagnosing and monitoring of treatment in patients with TB and HIV-TB coinfection.,,
In a study done by Suarez et al., it was seen that there is a synergistic effect of both the infections (HIV infection and TB) which causes a state of chronic inflammation resulting in a very high levels of cytokines, thus opening the door for exploring new adjuvant methods of monitoring and treating these patients. In our study, the median CD4 count was low and HIV 1 plasma viral load was high, which could be due to the complex interaction between HIV and TB where TB infection could have led to virological failure or that virological failure could have led to MTB infection. Most of the patients were smear negative in this study which would be expected due to their HIV-positive status and low CD4 count.
This study showed a significant reduction in levels of INF γ, IL-4, and IL-10 over 2 months of ATT. Preclinical studies have also shown a similar trend. A study done by Riou et al. showed a significant reduction in levels of interferon-gamma postinitiation of ATT and increase in IL-10 levels in patients with relapse of TB (13). Levels of INF γ and IL-10 can also be an indicator of disease severity. A study done by Mihret et al. showed that TH1 response in patients with TB varies with HIV status of the individual with HIV-positive patients showing impaired TH-1 response and no significant reduction in cytokines posttreatment of TB. In another study done by Riou C et al. showed that IP-10 showed a significant reduction after treatment of TB in both HIV-negative and HIV-positive patients. This reduction in cytokines postTB treatment in HIV-TB coinfection may be due to activation of multiple arms of immune response leading to reduction of inflammation and thus decrease in cytokine levels. Hence, cytokines may be an indicator to assess response of ATT in HIV-TB coinfection. However, more and larger studies are required to find the ideal biomarker to assess the response to ATT in HIV-TB coinfection.
In this study, we also found that IP-10 is significantly associated with low CD4 count in male patients. Similar association between IP-10 and CD4 count has been demonstrated in other studies., This association could not be demonstrated for female patients with HIV-TB coinfection as there were only 14% of female patients in our study. There was also no demonstrable correlation between HIV viral load and IP-10 levels which could be due to a small sample size in our study being a pilot study. Thus, IP-10 may be a promising biomarker in patients with HIV-TB coinfection with low CD4 count. The IP-10 levels may reflect the extent of the ongoing pro-inflammatory immune response. This finding may be even more significant in patients of HIV with low CD4 counts and in smear-negative cases where it may be difficult to assess response to therapy.
Strength of this study is that this is the first study from South-East Asia to assess the utility of biomarker to assess the efficacy of ATT in HIV-TB coinfection patients. The limitation of the study is that it was a pilot study with a small sample size with the majority of patients being male patients. Although skewed data regarding gender are not a major limitation, some studies do suggest that low CD4 count and increased virological failure in males., Moreover, all the biomarkers could not be assessed in this study. This study could not find a relation between CD4, plasma viral load HIV-1, and the levels of INFγ, IL-4, and IL-10 for which further studies with larger samples may be needed to find a relation.
| Conclusion|| |
This pilot study explored the levels of INF γ, IL-4, IL-10, and IP-10 cytokines over 2 months after initiation of ATT in patients with HIV-TB coinfection and their relation to CD4 and plasma viral load HIV-1. It found a significant decrease in INF γ, IL-4, and IL-10 over 2 months of ATT and IP-10 showing a significant negative association with CD4 counts in males. Findings in this pilot study will need to be confirmed by further studies toward developing a biomarker for assessing response to treatment in HIV-TB coinfection.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]