| ObjectiveTalaromyces marneffei(TM)is an opportunistic infection with high morbidity among HIV/AIDS patients in Southeast Asia and Southern China.The study aims to elucidate the effects of it on mortality in HIV/AIDS patients.Furthermore,we aim to explore the expression and its role of pattern recognition receptor(PRR)in HIV/TM co-infection patients.MethodsWe conducted a large-scale observational cohort study of hospitalized HIV-infected patients at the Fourth People's Hospital of Nanning,Guangxi,China during 2012-2015.The electronic medical record information includes demographic features,length of stay,treatment outcomes,CD4+ cells at admission,ART treatment status,and complications.From February 2017 to December 2017,we recruited patients with HIV-infected TM infection and patients with HIV-incompetent TM infection in the Fourth People's Hospital of Nanning,collected peripheral blood and isolated peripheral blood mononuclear cells(PBMC)to extracted RNA.The expression of cGAS-STING signaling pathway and TLR2/4/9 signaling pathway-associated factor mRNA was detected.Flow cytometry was used to detect the protein expression of key factors in the two signaling pathway in macrophages.Chi-square test was used to analyze the demographic data of the combined TM infection group and the non-merger TM infection group.Kaplan-Meier analyses were used to calculate the cumulative mortality.Cox proportional hazard models and 1:1 propensity score matching were utilized to evaluate the effects of TM infection on mortality of HIV infected patients.t-test,Chi-square test,and rank sum test were used to analyze the basic information,mRNA and protein levels of the two groups.Test level ?=0.05.Results1.In total,6791 HIV/AIDS patients were included in the retrospective cohort study.Most of subjects were 41-60 years old(39.8%),of which the vast majority were male(71.9%),Han(68.3%)and had married(64.0%),mainly occupational were farmers(52.9%).There were 1093 cases of AIDS patients with TM co-infection,which accounted for 16.1% of the total number of people.Mycobacterium tuberculosis infection(TB)accounted for 37.1%,pneumonia accounted for 47.6%,oral candida accounted for 30.4%,chronic hepatitis virus co-infection(HBV or HCV)accounted for 16.0%,immune reconstitution inflammatory syndrome(IRIS)accounted for 1.6%,cytomegalovirus infection accounted for 3.0%,herpes virus co-infection 4.9%.The TM co-infection rate ranks fourth in all complications.Most HIV/TM co-infection patients did not undergo antiretroviral therapy(ART)(64.0%)before admission.HIV/TM co-infection patients' CD4+ T cells less than 200/?L accounted for 79.9%,and were lower than those in the control group.The subjects also included multiple complications at the same time.The rate of other complications in patients with HIV/TM coinfection was higher than that of AIDS patients without TM infection(P<0.05).2.The mortality of HIV/TM co-infection patients was 17.5%,and the death density was 25.0 per 100 person-months(95% CI 21.5-26.7),while the mortality of without TM-infected patients was 7.6%,and the death density was 13.8/100 person-months(95% CI 12.5-15.1).There was a statistically significant difference in mortality between the two groups(P<0.05).The mortality rates and death densities associated with other common opportunistic infections were: pneumonia(15.2% and 23.1/100 person-months),oral candida(13.9% and 20.9/100 person-months),TB infection(9.9% and 13.5/ 100 person months).The mortality and death density of HIV/TM co-infection patients ranks first among AIDS-related complications.3.Compared with patients without TM infection,the hazard ratio(HR)of TM infection was 1.90(95% CI: 1.60-2.26).After adjustment for multiple factors,adjusted hazard ratio(AHR)was 1.80(95% CI 1.48-2.16).In a subgroup analysis of complications,TM infection increased the mortality risk of TB,pneumonia,oral candidiasis,and chronic hepatitis,with AHRs of 1.38(95% CI: 1.02-1.87)and 1.72(95%CI: 1.40-2.11),1.46(95%CI: 1.11-1.92),2.91(95%CI: 1.81-4.69),respectively.When stratified by general characteristics,TM infection has higher mortality risk in all stratifications.TM co-infection carries a higher mortality risk in patients with CD4 cell count of 200-349 cells/?L or above.The AHR of patients with 200-349 cells/?L was 11.60(95% CI: 4.27-31.55),and with 350 cells/?L above was 5.74(95% CI: 1.94-17.02).4.For the propensity score matching analysis,the numbers of subjects in the two groups were 346,respectively.All factors were balanced exclude TM infection.The mortality and death densities of AIDS patients with TM infection were 15.3% and 23.2 per 100 person-months(95%CI: 17.1-29.3),respectively,while those without TM infection were 4.0% and 6.1 per 100 person-months(95%CI: 3.0-9.2),respectively.The AHR was 4.52(95% CI: 2.43-8.42).5.This study recruited 15 AIDS patients with TM infection and 20 AIDS patients without TM infection.The distribution difference of other complications were not statistically significant.Results showed that mRNA expression of TLR2/4/9 and cGAS had a tendency to increase in the HIV/TM co-infected patients.While there was no statistically significant.Further testing other factors of TLR2/4/9 and cGAS-STING signaling pathways,the results were consistent with TLR2/4/9 and cGAS.6.At the protein expression level,among TLR2/4/9 and cGAS,only TLR4 was significantly different between AIDS patients with TM infection and without TM infection(p<0.05).The average fluorescence intensity of TLR4 in AIDS patients with TM infection was 262200 ± 95480,which was higher than that of AIDS patients without TM infection(153100 ± 41410).The protein expression of MyD88,TBK1,IRF7 in AIDS patients with TM infection were 481200±244900,223400±72320,and 230400±111600,respectively,which were higher than those in AIDS patients without TM infection(190300±100500,141600±38460,143100±41020)(P<0.05);We also found that the expression of IFN-? and IL-6 in the AIDS patients with TM infection(20610±6418,8285±2492)were higher than those in AIDS patients with TM infection(14720±4205,4602±1979)(P <0.05).7.Considering that different levels of CD4+ T cells affect the expression of PRR pathway,we further analyzed the expression level of PRR pathway in different CD4+ T cells.It was shown that in the population with CD4+T cell less than 200 cells/?L,only TLR4,MyD88,TBK1,IRF7,IL-6,and IFN-? expressions were significantly different between AIDS patients with TM infection and without TM infection(P<0.05).And the expression level of AIDS patients with TM infection was higher than control group.Furthermore,only the cases with CD4+ T cells less than 100 cells/?L were analyzed.The results showed that the protein expressions of TLR4,MyD88,TBK1,IRF7,and IL-6 in AIDS patients with TM infection were higher than control group,with a statistically significant difference(P<0.05).ConclusionTM infection is commonly found in hospitalized HIV/AIDS patients in southern China,and was associated with higher mortality than most AIDS-associated complications.HIV/TM co-infection can significantly increase the risk of death for AIDS patients.TLR4 signaling pathway and IFN-? leads to the over-activation of immune responses and thus play a key role for death of the HIV/TM co-infection patients.This study provides epidemiological evidences for strengthening the early ART and antifungal treatment of HIV/TM co-infection patients.The study of relevant mechanisms also lays the foundation for the development of new drug targets and treatment protocols based on innate immune pattern recognition receptors. |
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