Justine K Nakiwala1,2,3, Naomi F Walker1,4, Collin R Diedrich1,5, William Worodria6, Graeme Meintjes1,7, Robert J Wilkinson1,7,8, Harriet Mayanja-Kizza6, Robert Colebunders2,9, Luc Kestens2,3, Katalin A Wilkinson1,8, David M Lowe1,7,10. 1. Department of Medicine, Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa. 2. Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium. 3. Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium. 4. Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom. 5. Pediatrics, Division of Infectious Disease, Children's Hospital of UPMC, University of Pittsburgh, Pittsburgh, PA. 6. Department of Medicine, Mulago Hospital, College of Health Sciences, Makerere University, Kampala, Uganda. 7. Department of Medicine, Imperial College London, London, United Kingdom. 8. The Francis Crick Institute, London, United Kingdom. 9. Global Health Institute, University of Antwerp, Antwerp, Belgium. 10. Institute of Immunity and Transplantation, University College London, London, United Kingdom.
Abstract
BACKGROUND: Tuberculosis immune reconstitution inflammatory syndrome (TB-IRIS) remains incompletely understood. Neutrophils are implicated in tuberculosis pathology but detailed investigations in TB-IRIS are lacking. We sought to further explore the biology of TB-IRIS and, in particular, the role of neutrophils. SETTING: Two observational, prospective cohort studies in HIV/TB coinfected patients starting antiretroviral therapy (ART), 1 to analyze gene expression and subsequently 1 to explore neutrophil biology. METHODS: nCounter gene expression analysis was performed in patients with TB-IRIS (n = 17) versus antiretroviral-treated HIV/TB coinfected controls without IRIS (n = 17) in Kampala, Uganda. Flow cytometry was performed in patients with TB-IRIS (n = 18) and controls (n = 11) in Cape Town, South Africa to determine expression of neutrophil surface activation markers, intracellular cytokines, and human neutrophil peptides (HNPs). Plasma neutrophil elastase and HNP1-3 were quantified using enzyme-linked immunosorbent assay. Lymph node immunohistochemistry was performed on 3 further patients with TB-IRIS. RESULTS: There was a significant increase in gene expression of S100A9 (P = 0.002), NLRP12 (P = 0.018), COX-1 (P = 0.025), and IL-10 (P = 0.045) 2 weeks after ART initiation in Ugandan patients with TB-IRIS versus controls, implicating neutrophil recruitment. Patients with IRIS in both cohorts demonstrated increases in blood neutrophil count, plasma HNP and elastase concentrations from ART initiation to week 2. CD62L (L-selectin) expression on neutrophils increased over 4 weeks in South African controls whereas patients with IRIS demonstrated the opposite. Intense staining for the neutrophil marker CD15 and IL-10 was seen in necrotic areas of the lymph nodes of the patients with TB-IRIS. CONCLUSIONS: Neutrophils in TB-IRIS are activated, recruited to sites of disease, and release granule contents, contributing to pathology.
BACKGROUND: Tuberculosis immune reconstitution inflammatory syndrome (TB-IRIS) remains incompletely understood. Neutrophils are implicated in tuberculosis pathology but detailed investigations in TB-IRIS are lacking. We sought to further explore the biology of TB-IRIS and, in particular, the role of neutrophils. SETTING: Two observational, prospective cohort studies in HIV/TB coinfected patients starting antiretroviral therapy (ART), 1 to analyze gene expression and subsequently 1 to explore neutrophil biology. METHODS: nCounter gene expression analysis was performed in patients with TB-IRIS (n = 17) versus antiretroviral-treated HIV/TB coinfected controls without IRIS (n = 17) in Kampala, Uganda. Flow cytometry was performed in patients with TB-IRIS (n = 18) and controls (n = 11) in Cape Town, South Africa to determine expression of neutrophil surface activation markers, intracellular cytokines, and human neutrophil peptides (HNPs). Plasma neutrophil elastase and HNP1-3 were quantified using enzyme-linked immunosorbent assay. Lymph node immunohistochemistry was performed on 3 further patients with TB-IRIS. RESULTS: There was a significant increase in gene expression of S100A9 (P = 0.002), NLRP12 (P = 0.018), COX-1 (P = 0.025), and IL-10 (P = 0.045) 2 weeks after ART initiation in Ugandan patients with TB-IRIS versus controls, implicating neutrophil recruitment. Patients with IRIS in both cohorts demonstrated increases in blood neutrophil count, plasma HNP and elastase concentrations from ART initiation to week 2. CD62L (L-selectin) expression on neutrophils increased over 4 weeks in South African controls whereas patients with IRIS demonstrated the opposite. Intense staining for the neutrophil marker CD15 and IL-10 was seen in necrotic areas of the lymph nodes of the patients with TB-IRIS. CONCLUSIONS: Neutrophils in TB-IRIS are activated, recruited to sites of disease, and release granule contents, contributing to pathology.
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