Sophia Siddiqui

Fulminant Mulch Pneumonitis: An Emergency Presentation of Chronic Granulomatous Disease

BACKGROUND Chronic granulomatous disease (CGD) is associated with multiple and recurrent infections. In patients with CGD, invasive pulmonary infection with Aspergillus species remains the greatest cause of mortality and is typically insidious in onset. Acute fulminant presentations of fungal pneumonia are catastrophic. METHODS Case records, radiograph findings, and microbiologic examination findings of patients with CGD who had acute presentations of dyspnea and diffuse pulmonary infiltrates caused by invasive fungal infection were reviewed and excerpted onto a standard format. RESULTS From 1991 through 2004, 9 patients who either were known to have CGD or who received a subsequent diagnosis of CGD presented with fever and new onset dyspnea. Eight patients were hypoxic at presentation; bilateral pulmonary infiltrates were noted at presentation in 6 patients and developed within 2 days after initial symptoms in 2 patients. All patients received diagnoses of invasive filamentous fungi; 4 patients had specimens that also grew Streptomyces species on culture. All patients had been exposed to aerosolized mulch or organic material 1-10 days prior to the onset of symptoms. Cases did not occur in the winter. Five patients died. Two patients, 14 years of age and 23 years of age, who had no antecedent history of recognized immunodeficiency, were found to have p47(phox)-deficient CGD. CONCLUSIONS Acute fulminant invasive fungal pneumonia in the absence of exogenous immunosuppression is a medical emergency that is highly associated with CGD. Correct diagnosis has important implications for immediate therapy, genetic counseling, and subsequent prophylaxis.

Failure to Recognize Nontuberculous Mycobacteria Leads to Misdiagnosis of Chronic Pulmonary Tuberculosis

Background Nontuberculous mycobacterial (NTM) infections cause morbidity worldwide. They are difficult to diagnose in resource-limited regions, and most patients receive empiric treatment for tuberculosis (TB). Our objective here is to evaluate the potential impact of NTM diseases among patients treated presumptively for tuberculosis in Mali. Methods We re-evaluated sputum specimens among patients newly diagnosed with TB (naïve) and those previously treated for TB disease (chronic cases). Sputum microscopy, culture and Mycobacterium tuberculosis drug susceptibility testing were performed. Identification of strains was performed using molecular probes or sequencing of secA1 and/or 16S rRNA genes. Results Of 142 patients enrolled, 61 (43%) were clinically classified as chronic cases and 17 (12%) were infected with NTM. Eleven of the 142 (8%) patients had NTM disease alone (8 M. avium, 2 M. simiae and 1 M. palustre). All these 11 were from the chronic TB group, comprising 11/61 (18%) of that group and all were identified as candidates for second line treatment. The remaining 6/17 (35.30%) NTM infected patients had coinfection with M. tuberculosis and all 6 were from the TB treatment naïve group. These 6 were candidates for the standard first line treatment regimen of TB. M. avium was identified in 11 of the 142 (8%) patients, only 3/11 (27.27%) of whom were HIV positive. Conclusions NTM infections should be considered a cause of morbidity in TB endemic environments especially when managing chronic TB cases to limit morbidity and provide appropriate treatment.

Adjuvant Host-Directed Therapy with Types 3 and 5 but Not Type 4 Phosphodiesterase Inhibitors Shortens the Duration of Tuberculosis Treatment

BACKGROUND Shortening tuberculosis treatment could significantly improve patient adherence and decrease the development of drug resistance. Phosphodiesterase inhibitors (PDE-Is) have been shown to be beneficial in animal models of tuberculosis. We assessed the impact of PDE-Is on the duration of treatment in tuberculous mice. METHODS We analyzed the time to death in Mycobacterium tuberculosis-infected mice receiving type 4 PDE-Is (rolipram and cilomilast) and the impact on bacterial burden, time to clearance, and relapse when types 3 and 5 PDE-Is (cilostazol and sildenafil, respectively) and rolipram were added to the standard treatment. We investigated pharmacokinetic interactions between PDE-Is (cilostazol and sildenafil) and rifampin. RESULTS The type 4 PDE-Is rolipram and cilomilast accelerated the time to death in tuberculous mice. The addition of rolipram to standard tuberculosis treatment increased bacterial burden and did not decrease the time to bacterial clearance in the lung, while the addition of the cilostazol and sildenafil reduced the time to clearance by 1 month. Cilostazol and sildenafil did not have negative pharmacokinetic interactions with rifampin. CONCLUSIONS Type 4 PDE-Is may increase the severity of tuberculosis and should be carefully investigated for use in patients with latent or active tuberculosis. Cilostazol and sildenafil may benefit tuberculosis patients by shortening the duration of therapy.

Molecular strain typing of Mycobacterium tuberculosis complex in Bamako, Mali

OBJECTIVE To identify strains of Mycobacterium tuberculosis complex (MTC) circulating in Bamako and to examine the relationship between the strains and their drug susceptibility profiles. METHODS Between 2006 and 2010, we conducted a cross-sectional study using spoligotyping to identify strains of MTC recovered from 126 tuberculosis (TB) patients under treatment in Bamako, Mali. RESULT Three members of the MTC were isolated: M. tuberculosis (71.4%), M. africanum (27.8%) and M. bovis (0.8%). Of these, three strains were found to be the most prevalent: M. tuberculosis T1 (MTB T1; 38.9%), M. africanum F2 (MAF2; 26.2%) and M. tuberculosis Latin American and Mediterranean 10 (MTB LAM 10; 10.3%). MAF2 and MTB LAM 10 strains have a lower risk of multidrug resistance (MDR) than MTB T1 (respectively OR 0.1, 95%CI 0.03-0.4 and OR 0.1, 95%CI 0.01-0.8). Age ≥ 32 years (OR 1.4, 95%CI 0.4-3.9), negative human immunodeficiency virus status (OR 0.4, 95%CI 0.1-2.5) and male sex (OR 4, 95%CI 0.9-16.5) were not associated with MDR. The prevalence of MDR among treatment and retreatment failure patients was respectively 25% and 81.8% compared to new patients (2.9%). CONCLUSION This study indicates a low level of primary drug resistance in Bamako, affirms the importance of using correct drug regimens, and suggests that the MTB T1 strain may be associated with the development of resistance.

RePORT International: Advancing Tuberculosis Biomarker Research Through Global Collaboration

Progress in tuberculosis clinical research is hampered by a lack of reliable biomarkers that predict progression from latent to active tuberculosis, and subsequent cure, relapse, or failure. Regional Prospective Observational Research in Tuberculosis (RePORT) International represents a consortium of regional cohorts (RePORT India, RePORT Brazil, and RePORT Indonesia) that are linked through the implementation of a Common Protocol for data and specimen collection, and are poised to address this critical research need. Each RePORT network is designed to support local, in-country tuberculosis-specific data and specimen biorepositories, and associated research. Taken together, the expected results include greater global clinical research capacity in high-burden settings, and increased local access to quality data and specimens for members of each network and their domestic and international collaborators. Additional networks are expected to be added, helping to spur tuberculosis treatment and prevention research around the world.

Tuberculosis drug resistance in Bamako, Mali, from 2006 to 2014

BackgroundAlthough Drug resistance tuberculosis is not a new phenomenon, Mali remains one of the “blank” countries without systematic data.MethodsBetween 2006 and 2014, we enrolled pulmonary TB patients from local TB diagnostics centers and a university referral hospital in several observational cohort studies. These consecutive patients had first line drug susceptibility testing (DST) performed on their isolates. A subset of MDR was subsequently tested for second line drug resistance.ResultsA total of 1186 mycobacterial cultures were performed on samples from 522 patients, including 1105 sputa and 81 blood samples, yielding one or more Mycobacterium tuberculosis complex (Mtbc) positive cultures for 343 patients. Phenotypic DST was performed on 337 (98.3%) unique Mtbc isolates, of which 127 (37.7%) were resistant to at least one drug, including 75 (22.3%) with multidrug resistance (MDR). The overall prevalence of MDR-TB was 3.4% among new patients and 66.3% among retreatment patients. Second line DST was available for 38 (50.7%) of MDR patients and seven (18.4%) had resistance to either fluoroquinolones or second-line injectable drugs.ConclusionThe drug resistance levels, including MDR, found in this study are relatively high, likely related to the selected referral population. While worrisome, the numbers remained stable over the study period. These findings prompt a nationwide drug resistance survey, as well as continuous surveillance of all retreatment patients, which will provide more accurate results on countrywide drug resistance rates and ensure that MDR patients access appropriate second line treatment.

Mycobacterium tuberculosis Beijing Strain, Bamako, Mali

To the Editor: Mycobacterium tuberculosis has >36 identified genotype families (1). Four genotypes cause 35% of documented cases of active tuberculosis (TB): Beijing (10%–11%), Latin American–Mediterranean (9.3%), Haarlem (7.5%), and the X clade (7%) (1,2) The Beijing clade strains, reported in 1995 from the People’s Republic of China, are widely recognized as highly pathogenic with a possible predilection for multidrug resistance (3). Predominant in Asia, these strains have been documented in other parts of the world (1,4,5). The virulence, propensity to become resistant, and distinct geographic distribution of the Beijing clade suggest it may have some adaptive advantage in producing disease in humans. Limited data suggest that its presence in Africa is low (2,4,5). In Bamako, Mali, 2 patients with active pulmonary TB came to the research clinic at Point G Hospital, affiliated with the University of Bamako Medical School, for recruitment under a US National Institute of Allergy and Infectious Diseases’ institutional review board–approved protocol. The first patient, a previously healthy 34-year-old man, sought treatment in March 2008. He had a 3-month history of fever, cough, shortness of breath, and left-sided chest pain; respiratory rate of 24/min; temperature of 36.8oC; and pulse rate of 68/min. He weighed 60 kg. His leukocyte count was 8,700 cells/μL, and he was positive for HIV-1 with a CD4+ T-cell count of 468 cells/μL. He reported contact with persons from other countries in Africa, China, and other parts of Asia. Chest radiograph showed a cavitary lesion on the left upper lobe and opacities throughout the left lung. Three sputum samples collected 3 days apart were digested and decontaminated with N-acetyl-L-cysteine, 4% NaOH; concentrated by high-speed centrifugation; stained with auramine-rhodamine; and evaluated by using fluorescent microscopy. The many acid-fast bacilli (AFB) seen were identified by using nucleic acid probes (AccuProbe, Gen-Probe, San Diego CA, USA). Antimycobacterial drug susceptibility was determined by using a manual indirect susceptibility test (mycobacterial growth indicator tube, AST SIRE System; BBL, Becton Dickinson, Franklin Lakes, NJ, USA) showed the isolate sensitive to isoniazid (0.1 μg/mL), rifampin (1.0 μg/mL), and ethambutol (3.5 μg/mL) but resistant to streptomycin (0.8 μg/mL). Spoligotyping using a commercially available kit (Spoligotyping Isogen Life Science, De Meern, the Netherlands) showed characteristics of the Beijing clade (Appendix Figure, panel A) (6). The patient began treatment with the standard first-line regimen of isoniazid, rifampin, pyrazinamide, and ethambutol fixed-dose combination (Svizera Laboratory, Mumbai, India) according to Malian National Guidelines. Follow-up sputum samples at 13 and 18 weeks of treatment were smear- and culture-negative for AFB. The second patient, a 28-year-old woman, sought treatment in July 2008. For 1 year, she had received first-line and retreatment regimens that failed to clear her sputum of AFB. She had begun second-line treatment for multidrug-resistant disease 2 days earlier. She had a history of fever, cough, and weight loss; temperature of 37.1oC; heart rate of 104 beats/min; respiratory rate of 24/min; and blood pressure of 90/60 Hg mm. She weighed 49 kg. Leukocyte count was 9,400 cells/μL. Serologic results for HIV-1 and -2 were negative. Chest radiograph showed a right apical cavitary lesion and a fibrotic lesion in the right middle lung field. She did not recall any exposure to TB. She worked as an assistant at a local telephone center. Two sputum samples, processed as described above, were positive for, and Gen-Probe testing confirmed, M. tuberculosis. According to antimycobacterial susceptibility testing, the strain was resistant to isoniazid (0.1 μg/mL), rifampin (1.0 μg/mL), ethambutol (3.5 μg/mL), and streptomycin (0.8 μg/mL). Spoligotyping confirmed the strain as Beijing clade, and restriction fragment length polymorphism (7) confirmed that it differed from that of patient 1 (Appendix Figure, panel B). The relevance of different genotypes, such as the Beijing clade, to disease progression is being studied. Evidence indicates the genotype may factor in transmission or pathogenesis. In a study in Cape Town, South Africa, disease produced by the Beijing clade increased exponentially over time, suggesting a possible pathogenic advantage; although most cases were drug susceptible, the likelihood of unsuccessful treatment was greater than for non-Beijing variants (8). Although the Beijing clade does not appear to have greater propensity than non-Beijing genotypes for acquiring resistance, certain variants within the group that become multidrug resistant may be more likely to acquire such resistance. Beijing strains particularly may tend to acquire resistance more easily than others under conditions of suboptimal treatment (9). In Cape Town during 2000–2003, the Beijing clade as a cause of disease in children increased from 13% to 33%, suggesting a selective advantage in transmissibility and disease production (10). These cases highlight the need to diagnose disease and resistance early and to begin appropriate treatment in TB-endemic countries. Knowledge of circulating strains and their resistance patterns is essential to developing effective programs to curtail the spread of TB within the country and the region; in this era of globalization, it is required for the successful control of TB worldwide.

Stool microbiome reveals diverse bacterial ureases as confounders of oral urea breath testing for Helicobacter pylori and Mycobacterium tuberculosis in Bamako, Mali.

Detection of bacterial urease activity has been utilized successfully to diagnose Helicobacter pylori (H. pylori). While Mycobacterium tuberculosis (M. tuberculosis) also possesses an active urease, it is unknown whether detection of mycobacterial urease activity by oral urease breath test (UBT) can be exploited as a rapid point of care biomarker for tuberculosis (TB) in humans. We enrolled 34 individuals newly diagnosed with pulmonary TB and 46 healthy subjects in Bamako, Mali and performed oral UBT, mycobacterial sputum culture and H. pylori testing. Oral UBT had a sensitivity and specificity (95% CI) of 70% (46-88%) and 11% (3-26%), respectively, to diagnose culture-confirmed M. tuberculosis disease among patients without H. pylori, and 100% sensitivity (69-100%) and 11% specificity (3-26%) to diagnose H. pylori among patients without pulmonary TB. Stool microbiome analysis of controls without TB or H. pylori but with positive oral UBT detected high levels of non-H. pylori urease producing organisms, which likely explains the low specificity of oral UBT in this setting and in other reports of oral UBT studies in Africa.

Tuberculosis specific responses following therapy for TB: Impact of HIV co-infection.

Characterizing perturbations in the immune response to tuberculosis in HIV can develop insights into the pathogenesis of coinfection. HIV+ TB+ and TB monoinfected (TB+) subjects recruited from clinics in Bamako prior to initiation of TB treatment were evaluated at time-points following initiation of therapy. Flow cytometry assessed CD4+/CD8+ T cell subsets and activation markers CD38/HLA-DR. Antigen specific responses to TB proteins were assessed by intracellular cytokine detection and proliferation. HIV+ TB+ subjects had significantly higher markers of immune activation in the CD4+ and CD8+ T cells compared to TB+ subjects. HIV+ TB+ had lower numbers of TB-specific CD4+ T cells at baseline. Plasma IFNγ levels were similar between HIV+ TB+ and TB+ subjects. No differences were observed in in-vitro proliferative capacity to TB antigens between HIV+ TB+ and TB+ subjects. Subjects with HIV+ TB+ coinfection demonstrate in vivo expansion of TB-specific CD4+ T cells. Immunodeficiency associated with CD4+ T cell depletion may be less significant compared to immunosuppression associated with HIV viremia or untreated TB infection.

Clinical characteristics of non-tuberculous mycobacterial pulmonary infections in Bamako, Mali

The global spread of non-tuberculous mycobacteria (NTM) may be due to HIV/AIDS and other environmental factors. The symptoms of NTM and tuberculosis (TB) disease are indistinguishable, but their treatments are different. Lack of research on the epidemiology of NTM infections has led to underestimation of its prevalence within TB endemic countries. This study was designed to determine the prevalence and clinical characteristics of pulmonary NTM in Bamako. A cross-sectional study which include 439 suspected cases of pulmonary TB. From 2006 to 2013 a total of 332 (76%) were confirmed to have sputum culture positive for mycobacteria. The prevalence of NTM infection was 9.3% of our study population and 12.3% of culture positive patients. The seroprevalence of HIV in NTM group was 17.1%. Patients who weighed <55 kg and had TB symptoms other than cough were also significantly more likely to have disease due to NTM as compared to those with TB disease who were significantly more likely to have cough and weigh more than 55 kg (OR 0.05 (CI 0.02-0.13) and OR 0.32 (CI 0.11-0.93) respectively). NTM disease burden in Bamako was substantial and diagnostic algorithms for pulmonary disease in TB endemic countries should consider the impact of NTM.