Biomarkers for discrimination between latent tuberculosis infection and active tuberculosis disease
Introduction
Tuberculosis (TB) is a leading global public health problem with high morbidity and mortality in humans.1 Although most individuals infected with Mycobacterium tuberculosis (Mtb) remain healthy, a state referred to as latent TB infection (LTBI), approximately 10% of these individuals will eventually develop active TB.2 The development of a rapid diagnostic test that can distinguish between active TB and LTBI or active TB and non-active TB, as well as detect Mtb infection, is very important for TB control. There is no gold standard for diagnosis of Mtb infection, and, until recently, the tuberculin skin test (TST) was the only tool available for detecting LTBI. Interferon (IFN)-gamma release assays (IGRAs), which depend on the detection of a single cytokine, IFN-γ, in response to Mtb-specific antigens, have been introduced as an alternative to TST for the diagnosis of Mtb infection. However, both TST and IGRA are intrinsically unable to discriminate between active TB and LTBI.3 In addition, even with active TB patients in a high-burden setting, these assays show low sensitivity because of advanced disease, malnutrition, and immunosuppression in patients, as well as low specificity due to a high background prevalence of LTBI.4
To address these limitations, new techniques, including transcript microarrays, flow cytometry of intracellular cytokines, and multiplex microbead-based immunoassay (Luminex assay) of cytokines, have recently been introduced.5, 6, 7, 8, 9 In these studies, the simultaneous detection of multiple analytes rather than a single analyte has been found to be a promising approach to discriminate between active TB and LTBI. More specifically, the combination of soluble CD40 ligand (sCD40L), epidermal growth factor (EGF), IFN-α, interleukin (IL)-1α, IL-1 receptor antagonist (IL-1RA), IL-4, IL-12 (p40), IL-15, IL-17, macrophage inflammatory protein (MIP)-1β, monocyte chemotactic protein (MCP)-1, transforming growth factor (TGF)-α, tumor necrosis factor (TNF)-α, or vascular endothelial growth factor (VEGF) responses after stimulation with Mtb-specific antigens, as measured by Luminex assay, has been reported for the rapid differential diagnosis of active TB versus LTBI. However, these studies have selected different cytokines to detect active TB, and far less is known about the reliability of selected cytokines for the diagnosis of active TB. Therefore, the clinical relevance of cytokine responses remains to be clarified.
The aims of the present study were to assess 29 background-corrected Mtb-specific antigen-stimulated cytokine/chemokine biomarker levels in supernatants from the whole blood IGRA obtained from 4 major diagnostic groups, including Mtb-uninfected healthy controls (HCs), LTBI, IGRA-negative active TB, and IGRA-positive active TB, to examine whether these biomarkers can increase the sensitivity of detecting Mtb-infected individuals, especially patients with IGRA-negative active TB, and to determine whether such biomarkers can discriminate between active TB and LTBI or between active TB and non-active TB.
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Subjects
A total of 48 culture-confirmed active TB patients, 15 LTBI subjects, and 13 HCs were recruited at Chonnam National University Hospital, Gwangju, South Korea. All enrolled subjects were negative for anti-human immunodeficiency (HIV) antibody. All active TB were pulmonary TB and was diagnosed based on the guidelines of the American Thoracic Society and the U.S. Centers for Disease Control and Prevention.10 Active TB patients were divided into two experimental groups according to IGRA results:
Study subjects
A total of 76 subjects, including 48 active TB patients, 15 LTBI subjects, and 13 HCs were enrolled in this cohort study. According to QFT results, 48 active TB patients were subdivided into two groups: 36 patients with QFT-positive active TB (TBQFT+) and 12 patients with QFT-negative active TB (TBQFT−). The clinical and demographic characteristics of the study subjects are summarized in Table 1. No LTBI subjects were receiving LTBI treatment at the time of sampling.
Signatures of biomarkers in unstimulated supernatants
Of 29 total biomarkers
Discussion
To the best of our knowledge, this study determined the most extensive list of cytokine/chemokine biomarkers able to detect Mtb-infected individuals (8 biomarkers) or discriminate between active TB and LTBI (8 biomarkers) from residual QFT samples obtained from participants in HC, LTBI, and active TB populations. Importantly, combinations of these biomarkers were found to improve the potential to detect Mtb-infected individuals, particularly in active TB patients that were undetectable with
Conflict of interest
No potential conflict of interest relevant to this article was reported.
Acknowledgments
This study was supported by the National Research Foundation of Korea funded by the Korean Government (Grant 2015R1D1A1A01059762) and the Chonnam National University Hospital Biomedical Research Institute (Grant CRI15003-1 and CRI16011-1).
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2022, TuberculosisCitation Excerpt :Interestingly, as well as IL-6 and MMP-1, elevated levels of VEGF were observed in all PTB age groups. Literature data shows that increased IL-6, IL-17A and MMP-1 values were associated with active TB and higher concentrations of VEGF and elevated IL-2/IFN-γ ratio was observed in PTB patients in comparison with LTBI in adolescents and adults [16]. Recently, a study performed with children between 0 and 14 years-old identified that interferon gamma-induced protein 10 (IP-10), IFN-γ, ferritin and 25-hydroxyvitamin D can be combined to distinguish active TB from LTBI [17].
CCL1 and IL-2Ra differentiate Tuberculosis disease from latent infection Irrespective of HIV infection in low TB burden countries
2021, Journal of InfectionCitation Excerpt :To be valuable in resource-limited settings, however, such tests should preferably be based on point of care (POC) diagnostic technologies, for example, lateral flow-based tests, which are easily deployable in such environments. Numerous soluble host biomarkers for diagnosing TB10–12 and differentiating between M.tb infection (LTBI) and TB disease have been identified in both QuantiFERON supernatants,10,13–18 and in unstimulated ex-vivo plasma or serum samples.19–21 Although antigenic stimulation of blood samples may result in a more specific immune response to M.tb and consequently the production of M.tb-specific biomarkers, the detection of such biomarkers in unstimulated samples as plasma may be preferable for future test development with shorter turnaround times.
Combined analysis of whole blood interferon gamma release assay and complete blood count analysis for rapid discrimination of active tuberculosis and latent tuberculosis infection
2021, Journal of Clinical Tuberculosis and Other Mycobacterial DiseasesIL-1RA in the supernatant of QuantiFERON-TB Gold In-Tube and QuantiFERON-TB Gold Plus is useful for discriminating active tuberculosis from latent infection
2021, Journal of Infection and ChemotherapyCitation Excerpt :Finally, we generated ROC curves to distinguish active TB from LTBI and found that the levels of IL-1RA in GIT Ag tubes showed the highest AUC of 0.8367. Some cytokines were found to be useful in discriminating active TB from LTBI in the present study and this finding was in line with that reported in some of the previous studies including ours’ [7–10]. We had previously reported in a retrospective study that IFN-γ, IL-1RA, IL-2, and CCL2/MCP-1 in QFT-GIT supernatants were useful for discriminating LTBI from active TB [7].
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EJW and JHC contributed equally to this work.