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Multidrug-resistant Tuberculosis

MDR TB

Multi-drug resistant tuberculosis is an infectious disease caused by determined strains of Mycobacterium tuberculosis that are resistant to at least both isoniazid and rifampin, the two most commonly used antimicrobials to treat tuberculosis. Multi-drug resistance severely limits available treatment options.

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Presentation

Clinical presentation of patients suffering from MDR-TB or XDR-TB does not differ substantially from that of individuals who develop TB due to an infection with susceptible strains. In brief, symptoms characteristic of TB comprise fever, chills, night sweats, loss of appetite and weight loss, as well as complaints indicating compromise of the respiratory tract. Patients frequently claim breathing difficulties, productive cough and hemoptysis. However, TB is a multi-systemic disease and eventually, mycobacteria may compromise the gastrointestinal tract,urinary tract, the skin, the heart and the central nervous system.

The hallmark of MDR-TB is resistance to common treatment regimens. First-line treatment comprises the combined application of rifampicin, isoniazid, pyrazinamide, and ethambutol for two months followed by isoniazid and rifampicin for another four months. This approach to therapy is associated with rapid decreases of bacterial loads, relief of symptoms and better chances of success - unless the etiological agent is resistant to several of those drugs. Accordingly, disease exacerbation is common if MDR-TB patients are subjected to standard therapy. In general, patients who fail to respond to the intensive phase of standard therapy are highly suspicious of MDR-TB.

About one in ten individuals who contracted MDR-TB is immunodeficient, most commonly due to HIV infection. In some geographic regions, prevalence of HIV among MDR-TB patients is even higher [11]. HIV patients present with lethargy, fever, lymphadenopathy, multiple, and recurrent opportunistic infections. Thus, non-specific symptoms of TB resemble those of HIV, which may lead to a co-morbidity being overlooked.

Fever
  • She subsequently developed a rash, flu-like symptoms and fever, which progressed to acute hepatic necrosis despite discontinuation of medication.[ncbi.nlm.nih.gov]
  • A 27-year-old homosexual male was admitted for fever, cough, and hepatitis. At the time of admission, the p24 antigen was detected in his serum, indicating that he had an acute human immunodeficiency virus infection.[ncbi.nlm.nih.gov]
  • We report a 22-year-old CF patient with high fever, dyspnea and weight loss that progressively worsened over 2 weeks before admission.[ncbi.nlm.nih.gov]
  • Stigmata of TB were cough 3 weeks in 4, weight loss or a history of failing to thrive in 3, fever in 2 infants, and reported night sweats in 1. Chest radiographs at diagnosis revealed lymphadenopathy, lobar opacification, and airway narrowing.[ncbi.nlm.nih.gov]
  • In brief, symptoms characteristic of TB comprise fever, chills, night sweats, loss of appetite and weight loss, as well as complaints indicating compromise of the respiratory tract.[symptoma.com]
Weight Loss
  • We report a 22-year-old CF patient with high fever, dyspnea and weight loss that progressively worsened over 2 weeks before admission.[ncbi.nlm.nih.gov]
  • Stigmata of TB were cough 3 weeks in 4, weight loss or a history of failing to thrive in 3, fever in 2 infants, and reported night sweats in 1. Chest radiographs at diagnosis revealed lymphadenopathy, lobar opacification, and airway narrowing.[ncbi.nlm.nih.gov]
  • loss during treatment; males and additional resistance to first line drugs (Ethambutol, Streptomycin).[ncbi.nlm.nih.gov]
  • The general symptoms of TB disease include feelings of sickness or weakness, weight loss, fever, and night sweats. The symptoms of TB disease of the lungs may also include coughing, chest pain, and coughing up blood.[geosalud.com]
Anemia
  • Forty-five percent of the children had malnutrition or anemia at the time of diagnosis, 29% had severe radiographic findings (defined as bilateral or cavitary disease), and 13% had extrapulmonary disease.[pediatrics.aappublications.org]
  • Admission baseline investigations showed anemia. Renal and liver functions were within normal limits (Table 1 ).[casesjournal.biomedcentral.com]
  • […] included the following: extent of pulmonary parenchymal damage; number of previous treatments; low body-mass index (the weight in kilograms divided by the square of the height in meters), defined as less than 18.5 for women and less than 20 for men 36 ; anemia[doi.org]
Fatigue
  • […] right away if you have any of the following symptoms: Fever for 3 or more days Pain in the lower abdomen Itchiness or a rash Nausea, vomiting, or no appetite Yellowish skin or eyes Dark or brown urine Tingling, burning, or numbness of the hands and feet Fatigue[webmd.com]
  • […] away if you have any of the following symptoms: Fever for 3 or more days Pain in the lower abdomen Itchiness or a rash Nausea , vomiting , or no appetite Yellowish skin or eyes Dark or brown urine Tingling, burning, or numbness of the hands and feet Fatigue[webmd.com]
  • Most common symptoms were prolonged heavy cough, pain in the chest, high fever, profuse night sweats, fatigue, dyspnea, hemoptysis, and loss of weight and appetite.[doi.org]
Malaise
  • The illness was characterized by cough, weakness, malaise, fever, night sweats, shortness of breath, and hemoptysis. The patient's chest radiograph showed extensive cavitary disease that was highly suggestive of pulmonary tuberculosis (TB).[cdc.gov]
  • […] conjunctivitis, pruritic rash, convulsions including one HIV‐positive participant in the ciprofloxacin group in Kennedy 1993 who subsequently died, and hepatotoxicity in four participants with chronic liver disease that manifested with nausea, anorexia, malaise[doi.org]
Cough
  • A 27-year-old homosexual male was admitted for fever, cough, and hepatitis. At the time of admission, the p24 antigen was detected in his serum, indicating that he had an acute human immunodeficiency virus infection.[ncbi.nlm.nih.gov]
  • Stigmata of TB were cough 3 weeks in 4, weight loss or a history of failing to thrive in 3, fever in 2 infants, and reported night sweats in 1. Chest radiographs at diagnosis revealed lymphadenopathy, lobar opacification, and airway narrowing.[ncbi.nlm.nih.gov]
  • The symptoms of TB disease of the lungs may also include coughing, chest pain, and coughing up blood. Symptoms of TB disease in other parts of the body depend on the area affected.[geosalud.com]
Hemoptysis
  • Hemoptysis is the commonest mode of presentation, with an incidence of around 80%, which is life threatening in 30% [ 7 ].[casesjournal.biomedcentral.com]
  • He declined surgery and died in August 1987 from hemoptysis caused by TB. In 1976 and 1981, TB was diagnosed in two different relatives (patients 2 and 3) of the index patient.[cdc.gov]
  • Patients frequently claim breathing difficulties, productive cough and hemoptysis.[symptoma.com]
  • Most common symptoms were prolonged heavy cough, pain in the chest, high fever, profuse night sweats, fatigue, dyspnea, hemoptysis, and loss of weight and appetite.[doi.org]
Persistent Cough
  • Symptoms of TB Symptoms include a persistent cough, fever, weight loss, chest pain and breathlessness in the lead up to death.[msf.org.uk]
  • The symptoms of TB include a persistent cough, weight loss, and night sweats.[doi.org]
Dyspnea
  • We report a 22-year-old CF patient with high fever, dyspnea and weight loss that progressively worsened over 2 weeks before admission.[ncbi.nlm.nih.gov]
  • […] drugs in the regimen; age; sex; household size; history of homelessness, substance abuse, or institutionalization; medical history and coexisting conditions; respiratory difficulty, observed as tachypnea at rest (more than 26 breaths per minute), 38 dyspnea[doi.org]
  • Most common symptoms were prolonged heavy cough, pain in the chest, high fever, profuse night sweats, fatigue, dyspnea, hemoptysis, and loss of weight and appetite.[doi.org]
Pleural Effusion
  • We describe an HIV-infected patient with pleural and lymph node tuberculosis diagnosed by pleural effusion characteristics and biopsy specimens, without MT identification, that further presented with knee-joint involvement.[ncbi.nlm.nih.gov]
  • In all 18, chest radiographs revealed infiltrates (17 patients), hilar or mediastinal lymphadenopathy (12), or pleural effusions (8). (In one patient there were no infiltrates, but M. tuberculosis grew in a culture of his sputum.)[doi.org]
Loss of Appetite
  • The disease may lead to underweight and micro-nutrient defiencies by increasing energy requirements, poor metabolism and loss of appetite.[sundaymail.co.zw]
  • In brief, symptoms characteristic of TB comprise fever, chills, night sweats, loss of appetite and weight loss, as well as complaints indicating compromise of the respiratory tract.[symptoma.com]
Chest Pain
  • The symptoms of TB disease of the lungs may also include coughing, chest pain, and coughing up blood. Symptoms of TB disease in other parts of the body depend on the area affected.[geosalud.com]
  • Symptoms of TB Symptoms include a persistent cough, fever, weight loss, chest pain and breathlessness in the lead up to death.[msf.org.uk]
Night Sweats
  • Stigmata of TB were cough 3 weeks in 4, weight loss or a history of failing to thrive in 3, fever in 2 infants, and reported night sweats in 1. Chest radiographs at diagnosis revealed lymphadenopathy, lobar opacification, and airway narrowing.[ncbi.nlm.nih.gov]
  • The general symptoms of TB disease include feelings of sickness or weakness, weight loss, fever, and night sweats. The symptoms of TB disease of the lungs may also include coughing, chest pain, and coughing up blood.[geosalud.com]
  • The illness was characterized by cough, weakness, malaise, fever, night sweats, shortness of breath, and hemoptysis. The patient's chest radiograph showed extensive cavitary disease that was highly suggestive of pulmonary tuberculosis (TB).[cdc.gov]
Confusion
  • Confused by her weight loss, Ms Barangire finally decided to visit Karoi District Hospital. There she was told she had multi-drug resistant tuberculosis (MDR-TB).[sundaymail.co.zw]
  • I used to look so confused, I felt crazy.” Six months into the MDR-TB treatment, she started developing side effects. “My eyes turned yellow and I would not see clearly, my ears got blocked, people had to shout at me.[nation.co.ke]
  • The practice of reporting the prevalence of drug resistance as the proportion of cases with MDR tuberculosis is a further source of confusion regarding the global burden of drug resistance.[doi.org]
  • And while cycloserine — a drug nicknamed “psychoserine” for its notorious mental and behavioral effects — makes some patients hallucinate and scream, I got away with confusion. I had trouble with reading, organization, and paperwork.[buzzfeed.com]

Workup

Ideally, isolation of mycobacteria is followed by susceptibility tests in all cases of suspected TB, but such continuous surveillance of resistances to tuberculostatics is implemented only in a few countries. In any case, the following anamnestic data increase the likelihood of a TB patient to be infected with drug-resistant strains and thus emphasize the need for susceptibility evaluation.

  • Medical history of TB
  • Interruption of TB treatment
  • Exposure to MDR-TB patients

Unfortunately, standard procedures to ascertain the susceptibility of an isolate to isoniazid, rifampicin and other antibiotics are tedious and slow. After culture of mycobacteria to confirm TB, pathogens are maintained in liquid or solid media containing critical concentrations of antimicrobials. Subsequent colony counts will reveal whether the respective strain is susceptible to tested drugs, but results are only available after several weeks of bacterial culture. Liquid media favor the growth of mycobacteria, but are more expensive [12].

In recent years, molecular biological confirmation of TB and prediction of drug resistance has therefore been a subject of intense research. Different test procedures have been developed, e.g., the GenoType MTBDRplus and INNO-LiPA Rif.TB line probe assays and the Xpert MTB/RIF assay [13]. All these assays detect mutations of the rpoB gene related to rifampin resistance with acceptable sensitivity and specificity; sequence anomalies conferring resistance to isoniazid may only be revealed by the GenoType MTBDRplus assay. The GenoType MTBDRsl assay has been derived from the latter and may be applied to assess susceptibility to fluoroquinolones and second-line drugs in cases of suspected XDR-TB.

Lymphocytes Increased
  • In particular, the percentage of lymphocytes increased among V5 treated patients (from 22.5 6.8 to 29.5 6.7; P 2.8E-005) while patients in the control group failed to display any significant changes (21.2 8.9 vs 21.4 9.7; P 0.91).[doi.org]
Pleural Effusion
  • We describe an HIV-infected patient with pleural and lymph node tuberculosis diagnosed by pleural effusion characteristics and biopsy specimens, without MT identification, that further presented with knee-joint involvement.[ncbi.nlm.nih.gov]
  • In all 18, chest radiographs revealed infiltrates (17 patients), hilar or mediastinal lymphadenopathy (12), or pleural effusions (8). (In one patient there were no infiltrates, but M. tuberculosis grew in a culture of his sputum.)[doi.org]

Treatment

MDR-TB requires treatment with tuberculostatics that are less effective than isoniazid and rifampicin and/or are less well tolerated. Use of the following compounds may be considered [14].:

Ideally, the therapy of an individual patient is tailored based on the results of susceptibility tests. It is particularly important to distinguish MDR-TB (resistance to isoniazid and rifampicin) from XDR-TB (additional resistance to fluorquinolones and second-line therapeutics). However, test results may not be readily available and a more generalized approach to MDR-TB therapy needs to be followed in the meantime. In that case, at least one drug of each of the first four groups described above should be administered. If reasonable, pyrazinamide, one fluorquinolone, one injectable drug, and cycloserine or ethionamide are combined. So-called group 5 drugs are only prescribed if a regimen cannot be completed because of lack of effectivity of majority of the medications. Treatment regimens extend over 18 to 24 months, with possible reduction to a more restricted treatment after 6 months.

Prognosis

MDR-TB and XDR-TB are generally associated with a poor outcome, especially in immunocompromised patients who develop detrimental complications in particularly short periods of time. According to a recent study conducted in South Africa, one-month survival rates are 60% and 49% in HIV patients diagnosed with MDR-TB and XDR-TB, respectively [10]. One year after diagnosis, only 29% and 17% of those patients remain alive. In general, treatment success rates have been reported to be 86% and 60% for uncomplicated and MDR-TB, respectively [1] [2]. Presumably, these rates vary depending on the availability of medical care, appropriate diagnosis and availability of an alternative medication. Worldwide, 190,000 deaths have been ascribed to infections with multi-drug resistant strains of Mycobacterium spp. in 2014.

Etiology

The vast majority of TB cases is caused by infection with M. tuberculosis, but M. bovis and M. africanum may also trigger the disease. Mycobacteria may develop resistances to antimicrobial compounds, possibly by horizontal gene transfer [3]., but the molecular mechanisms underlying drug resistance are only partially understood. To this end, further research is urgently needed since the identification of genes involved in multiple drug resistance is of major importance not only for epidemiologists, but also in order to design diagnostic assays that allow for an early distinction between uncomplicated TB and MDR-TB. According to current knowledge, resistance to isoniazid is primarily caused by mutations of the pathogen's catalase-peroxidase-coding katG gene, while rifampin resistance is conferred by determined variants of the gene encoding for RNA polymerase β-subunit (rpoB gene) [4]. Furthermore, mutations of the inhA promoter, ndh and oxyR-ahpC have been related to drug resistance of M. tuberculosis. An increased expression of drug efflux pumps may partially explain the phenotype displayed by resistant strains [5]. Moreover, XDR-TB is defined as TB due to infection with mycobacteria displaying additional resistance to "any fluoroquinolone and any of the second-line anti-TB injectable drugs (amikacin, kanamycin or capreomycin)" [2]., and gyrA and gyrB mutations have been related to fluoroquinolone resistance [6]. For further information, the interested reader is referred to an excellent review detailing the genetic basis of multiple drug resistance in mycobacteria [7].

Epidemiology

MDR-TB (including XDR-TB) has been estimated to account for almost 5% of TB cases registered annually, and this corresponds to about 480,000 cases worldwide [1]. Epidemiologists are not only alarmed by the absolute increase of MDR-TB incidence, but also by the wide distribution of resistant strains: MDR-TB has been reported in more than 100 countries to date, with most cases being diagnosed in China and India [2]. Particularly high ratios of MDR-TB (>10%) have been observed in Azerbaijan, Estonia, Kazakhstan, Latvia, Republic of Moldova, Russian Federation, Tajikistan, Ukraine and Uzbekistan. However, spread of mycobacteria displaying multi-drug resistance is not restricted to low-income countries. Reliable data provided by the authorities of the United Kingdom indicate an that the number of MDR-TB cases almost tripled from 2000 to 2012 [8].

Sex distribution
Age distribution

Pathophysiology

It is generally accepted that development of drug resistances is an evolutionary process that allows pathogens to cope with selection pressure. There is a high correlation between the incidence of MDR-TB and previous exposure to anti-TB medications [9]. Unfortunately, considerable shares of TB patients require re-treatment with first-line drugs despite compliance with their physician's recommendations. Also, TB treatment regimens comprise several months of medication, and insufficient compliance with the length of therapy may promote the selection of resistant subpopulations of bacteria. In this context, high community rates of MDR-TB and close contact to infected persons have been identified as additional risk factors for developing MDR-TB, and those conditions are often mutually dependent.

Upon cessation of selection pressure, pathogens tend to lose genes conferring drug resistance or they are enabled to avoid host defense mechanisms. This is due to an overall loss of fitness, and this process has long since been used in the development of attenuated strains for vaccine production. However, M. tuberculosis has been shown to have the capacity to regain fitness even though it conserves resistance genes. This may be possible owing to additional compensatory mutations. Such strains do not lag behind non-resistant isolates regarding pathogenicity and virulence, but are insensitive to common tuberculostatics. It has been warned that this may inevitably lead to the development of total drug resistant strains [7].

Prevention

As has been indicated above, prior treatment against TB is one of the main risk factors of MDR-TB and XDR-TB. This observation emphasizes the need for adherence to treatment recommendations, avoidance of underdosage and premature cessation of drug therapy, as well as patient compliance. In fact, patients with a history of lack of compliance should take their drugs under supervision. All patients should be repeatedly advised on the importance of the continuation of therapy, even if symptoms start to disappear and their general condition improves. It has been proposed to apply shorter regimens to subgroups of MDR-TB patients. If the patient is required to comply with therapy for only 9 months, they are more likely to comply with medical recommendations. However, evidence regarding the effectivity of this approach is still scarce and further studies are needed to validate this recommendation [14].

Moreover, general measures to prevent transmission of mycobacteria may be taken, e.g., vaccination and quarantine of affected individuals.

Summary

Tuberculosis (TB) is a major threat to human health worldwide. According to official data provided by the World Health Organization, almost 10 million people fall ill to TB each year, with more than 10% of those individuals being infected with the human immunodeficiency virus (HIV). The discovery of antimicrobials effective against Mycobacterium tuberculosis and other Mycobacterial species that may induce TB - allowed for a considerable reduction of morbidity and mortality associated with the disease. In this context, isoniazid and rifampin are most commonly applied to treat TB patients and are administered in a combined therapeutic regimen. However, up to 5% of TB cases are triggered by strains resistant to isoniazid and rifampin, and about 10% of those cases are caused by pathogens displaying even more complex resistance patterns [1]. These are referred to as multi-drug resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB). The prognosis of both MDR-TB and XDR-TB is poor, and it has been estimated that these severe infectious diseases accounted for approximately 190,000 deaths in 2014. Few years ago, only 150,000 deaths have been ascribed to infections with resistant strains worldwide [2]. These data indicate an increasing prevalence of multi-drug resistance in Mycobacterium spp., and this development is very alarming due to few remaining treatment options.

Patient Information

Tuberculosis (TB) is a major health concern worldwide with about 10 million new cases registered every year. TB is an infection that is triggered by a bacteria pertaining to the genus Mycobacterium. In most cases, the causative agent is Mycobacterium tuberculosis. In order to overcome TB, patients are subjected to prolonged therapies comprising the daily intake of four antibiotics, namely isoniazid, rifampin, pyrazinamide and ethambutol. For distinct reasons, bacteria may develop resistances to those compounds, i.e., one or more of the aforementioned antibiotics are rendered ineffective. If mycobacteria carry resistances to the two major therapeutic medications such as isoniazid and rifampin, the patient is diagnosed with multi-drug resistant tuberculosis (MDR-TB). Affected individuals fail to respond to standard therapy. Individualized treatment regimens have to be developed to cure MDR-TB patients. This usually consist of at least four compounds applied over the course of 18-24 months. Still, morbidity and mortality associated with MDR-TB remain high, and prophylaxis is preferred over treatment. The main risk factors for developing MDR-TB are previous exposure to tuberculostatics and interruption or premature cessation of anti-TB therapy. It is thus of utmost importance to comply with the treating physician's recommendations regarding TB and MDR-TB therapies.

References

Article

  1. World Health Organization. WHO Global Tuberculosis Report 2015. 2015; http://www.who.int/tb/Global_TB_Facts.pdf. Accessed 29 August, 2016
  2. World Health Organization. Multidrug and extensively drug-resistant TB (M/XDR-TB): 2010 global report on surveillance and response. 2010; http://apps.who.int/iris/bitstream/10665/44286/1/9789241599191_eng.pdf. Accessed 29 August, 2016
  3. Veyrier F, Pletzer D, Turenne C, et al. Phylogenetic detection of horizontal gene transfer during the step-wise genesis of Mycobacterium tuberculosis. BMC Evol Biol. 2009; 9:196.
  4. Tracevska T, Jansone I, Broka L, et al. Mutations in the rpoB and katG genes leading to drug resistance in Mycobacterium tuberculosis in Latvia. J Clin Microbiol. 2002; 40(10):3789-3792.
  5. Li G, Zhang J, Guo Q, et al. Efflux pump gene expression in multidrug-resistant Mycobacterium tuberculosis clinical isolates. PLoS One. 2015; 10(2):e0119013.
  6. Li J, Gao X, Luo T, et al. Association of gyrA/B mutations and resistance levels to fluoroquinolones in clinical isolates of Mycobacterium tuberculosis. Emerg Microbes Infect. 2014; 3(3):e19.
  7. Smith T, Wolff KA, Nguyen L. Molecular biology of drug resistance in Mycobacterium tuberculosis. Curr Top Microbiol Immunol. 2013; 374:53-80.
  8. Anderson LF, Tamne S, Brown T, et al. Transmission of multidrug-resistant tuberculosis in the UK: a cross-sectional molecular and epidemiological study of clustering and contact tracing. Lancet Infect Dis. 2014; 14(5):406-415.
  9. Nachega JB, Chaisson RE. Tuberculosis drug resistance: a global threat. Clin Infect Dis. 2003; 36(Suppl 1):S24-30.
  10. Gandhi NR, Shah NS, Andrews JR, et al. HIV coinfection in multidrug- and extensively drug-resistant tuberculosis results in high early mortality. Am J Respir Crit Care Med. 2010; 181(1):80-86.
  11. Dubrovina I, Miskinis K, Lyepshina S, et al. Drug-resistant tuberculosis and HIV in Ukraine: a threatening convergence of two epidemics? Int J Tuberc Lung Dis. 2008; 12(7):756-762.
  12. Lawson L, Emenyonu N, Abdurrahman ST, et al. Comparison of Mycobacterium tuberculosis drug susceptibility using solid and liquid culture in Nigeria. BMC Res Notes. 2013; 6:215.
  13. Drobniewski F, Nikolayevskyy V, Maxeiner H, et al. Rapid diagnostics of tuberculosis and drug resistance in the industrialized world: clinical and public health benefits and barriers to implementation. BMC Med. 2013; 11:190.
  14. World Health Organization. Guidelines for the programmatic management of drug-resistant tuberculosis. 2011; http://apps.who.int/iris/bitstream/10665/44597/1/9789241501583_eng.pdf. Accessed 29 August, 2016

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Last updated: 2019-07-11 20:04