| Objective:Multidrug resistance-tuberculosis(MDR-TB)is type of mycobacterium tuberculosis(MTB),which is proved to be resistant to at least isoniazid and rifampicin in vitro drug sensitivity test.With an estimated480,000 new cases of MDR-TB worldwide in 2015,the epidemic and spread of the disease put the global TB prevention and control effort under severe test.In the past 20 years,although many chemotherapy schemes have been proposed in the relevant international and domestic guidelines,they are still unable to effectively treat MDR-TB and control its prevalence.The pathogenesis of MDR-TB is related to multiple factors,among which the autoimmune status of patients is very important.The immune dysfunction may lead to the reduction of the ability of MTB clearance of infected persons,which leads to the poor effect of the current chemotherapy regimen for MDR-TB.Although they were treated by active antituberculous therapy,the clinical curative ratio is only 52%,which makes people focus on immunotherapy in patients with MDR-TB.MTB is an intracellular bacteria,the body's anti-tuberculosis immunity mainly depends on specific cellular immunity,and many cytokines can participate in this immune response,so the development of tuberculosis and the outcome are closely related to the different responses of the immune system to MDR-TB regulated by related cytokines,which is particularly important in the treatment of patients with MDR-TB.At present,the view that Thl/Th2 imbalance is closely related to the occurrence,development and prognosis of tuberculosis has been widely accepted.Further studies indicate that the occurrence,development and outcome of MDR-TB may be related to cytokines secreted by Treg cells and Th17 cells.So far,there are few studies on the role of these cytokines in the pathogenesis and development of MDR-TB in China.The purpose of this study is to observe the efficacy of traditional clinical anti-tuberculosis therapy compared with the same treatment plus immunotherapy in MDR-TB and to detect the dynamic changes of serum TGF-?,TNF-?,IL-17 and IL-22.In order to evaluate and judge the state of cellular immune function in different stages of MDR-TB patients,and to provide experimental basis for the immunotherapy of clinicians,the role and the effect of cytokines and immunomodulators in the treatment of MDR-TB were evaluated.This aims to open up a new way for immunotherapy of MDR-TB.Methods:From January 2015 to June 2017,80 MDR-TB patients who met the criteria for inclusion in the study in Hebei Provincial Chest Hospital were collected.Divide the multidrug resistance-tuberculosis(MDR-TB)into the observation group(M1 group)(n=40),the anti-tuberculosis immunem-odulator group(M2 group)(n=40),the anti-tuberculosis control group(C group)(n=40).After diagnosis,serum TGF-?,TNF-?,IL-17 and IL-22 were measured by enzyme-linked immunosorbent assay(ELISA)which were taken at three stages:before treatment(T0),6 months of treatment(T6),24 months of treatment(T24)to analyze the dynamic changes of immune state in different stages.The clinical efficacy of each group was observed at 6 months and 24months after treatment.Results:1 General information of patientsIn group 1 named M1,there were 40 cases of multidrug resistance-tuberculosis treated with anti-tuberculosis alone,including 23 males and 17females aged from 18 to 44(29.816±7.576),and the course of disease was from 0 to 94(53.552±22.853)months.For group 2 named M2,40 cases were contained under treatment of multi drug resistance-tuberculosis and anti tuberculosis immune regulator,including 20 males and 20 females aged from18 to 45(32.774±8.694);Duration of disease from 3 to 95(59.736±25.115)months.Sensitive anti tuberculosis treatment group(Group C)contained 40cases,among which 19 cases were male and 21 were female aged from 18 to42(31.058±6.647).Differences in gender,age and other general conditions showed no statistical significance(P>0.05),but they are comparable.Differences in duration of disease between M1 and M2 showed no statistical significance(P>0.05),also can be compared.2 Clinical observation2.1 Clinical symptomThe changes of clinical symptoms such as cough,expectoration,fever,fatigue,night sweating and hemoptysis were observed.The above symptoms were gradually improved to 40 patients in group C.After 6 months of treatment,38 patients'clinical symptoms disappeared,2 patients had the symptom of dry cough and follow up.According to the chemotherapeutic regimen for sensitive pulmonary tuberculosis,the drug treatment was stopped.By the time of T24,there were still 38 cases without clinical symptoms in group C(2 patients had the symptom of dry cough,but it had nothing to do with tuberculosis),8 patients in group M1 and 10 patients in group M2 after 6months of treatment.The clinical effective rate of group C was significantly higher than that of group M1(95.00%vs 20.00%,P<0.05)and group M2(95.00%vs 25.00%,P<0.05),while the clinical effective rate of group M1and group M2 was no statistical difference(20.00%vs 25.00%,P>0.05),22cases of clinical symptoms disappeared and 31 cases of clinical symptoms disappeared in group M2 out of 40 cases at the end of 24 months after treatment.The clinical effective rate of group M2 was significantly higher than that of group M1(77.50%vs 55.00%,P<0.05),but still lower than that of group C(77.50%vs 95.00%,P<0.05).2.2 Bacteriological observationThe negative culture of tuberculin sputum was used as negative culture for 3 consecutive times.After 6 months of treatment,tuberculin of all 40patients in group C turned to negative,and 40 patients in group C were still negative after 24 months of treatment.After 6 months of treatment,there were7 sputum negative cases in 40 patients in the group M1,and 11 casein the group M2.At this time,the negative conversion rate of sputum culture in group C was significantly higher than that in group M1(100.00%vs 17.50%,P<0.05)and group M2(100.00%vs 27.50%,P<0.05),while there was no statistical difference in the negative rate of sputum culture between group M1and group M2(17.50%vs 27.50%,P>0.05);At the end of 24 months after the treatment,there were 13 cases of sputum negative in the group M1 and 28cases of sputum negative in the group M2.The rate of sputum negative conversion in the group M2 was significantly higher than that in the group M1(70.00%vs 32.50%,P<0.05),but it was still lower than that in the group C(70.00%vs 100.00%,P<0.05).2.3 Imaging observationWith 64 rows chest plain CT as imaging observation index,the lesion absorption area was more than 1/2 of the basic lesion area as grade A,the lesion absorption area was 1/5-1/2 absorption area,the lesion absorption area was defined as grade B,the lesion absorption area was less than 1/5,and the lesion absorption area was defined as grade C.The lesion area was enlarged and was classified as grade D.After 6 months~'treatment,31 of the 40 patients in group C had a degree of improvement,7 had a degree of improvement up to grade B and 2 had a degree of improvement up to grade C,without any further deterioration of the imaging findings,effective patients(A+B)were 38 cases.Of the 40 patients in group M1,1 case had a degree of improvement up to grade A,11 cases had a degree of improvement up to grade B,19 cases had a degree of improvement to grade C,and 9 cases had imaging changes of grade D,effective patients(A+B)were 12 cases;Of the 40 patients in group M2,3 case had a degree of improvement up to grade A,14 cases had a degree of improvement up to grade B,16 cases had a degree of improvement to grade C,and 7 cases had imaging changes of grade D,effective patients(A+B)were 17 cases;The effective rate of the group M2 was lower than that of group C(42.50%vs95.00%,P<0.05),but significantly higher than that of group M1(42.50%vs30.00%,P<0.05).After 24 months of treatment(T24),the response rate of 40 patients in group C was not changed.Among 40 patients in group M1,2 patients had a degree of improvement and 17 patients had a degree of improvement,and the degree of improvement was grade B.15 cases had a degree of improvement to grade C,and 6 cases had imaging changes of grade D,effective patients(A+B)were 19 cases;In 40 cases of M2 group,4 cases improved to Grade A;24cases improved to Grade B;7 cases improved to Grade C;5 cases had imaging changes of grade D,effective patients(A+B)were 28 cases.At this time,the effective rate of group M 2 was still lower than that of group C(70.00%vs 95.00%,P<0.05),but still significantly higher than that of group M1(70.00%vs 47.50%,P<0.05).3 Results of serum cytokine test in each group3.1 Detection of serum TGF-?Before treatment,T0 stage,the level of serum TGF-?in group C was significantly lower than that in group M1[(3.282±0.258)ng/L vs(4.037±0.266)ng/L,P<0.05]and group M2[(3.282±0.258)ng/L vs(4.051±0.257)ng/L,P<0.05],while the level of serum TGF-?in group M1 was not significantly different from that in group M2[(4.037±0.266)ng/L vs(4.051±0.257)ng/L,P>0.05].After 6 months of standardized anti-tuberculosis treatment(T6 stage),there was no significant change in serum TGF-?level in group C[(3.270±0.244)ng/L vs(3.282±0.258)ng/L,P>0.05],but the level of serum TGF-?in group M1 and M2 decreased[M1:(3.873±0.244)ng/L vs(4.037±0.266)ng/L,P<0.05;M2:(3.707±0.210)ng/L vs(4.051±0.257)ng/L,P<0.05],the levels of TGF-?in group M1 and group M2 were still higher than those in group C[(3.873±0.244)ng/L vs(3.270±0.244)ng/L,P<0.05;(3.707±0.210)ng/L vs(3.270±0.244)ng/L,P<0.05].Andthe serum levels of TGF-?decreased in both M1 and M2 groups were similar,there were no significant differences in serum TGF-?levels between group M1 and group M2[(3.873±0.244)ng/L vs(3.707±0.210)ng/L,P>0.05].M1 and M2continued to regulate antituberculous therapy for 24 months(T24),and serum TGF-?levels continued to decrease in group M2[(3.707±0.210)ng/L vs(3.323±0.232)ng/L,P<0.05],but the expression level of serum TGF-?in group M1 was not significantly changed with T6 stage[(3.853±0.249)ng/L vs(3.873±0.244)ng/L,P>0.05],and during the same period(T24 stag),the serum TGF-?level in group C was still higher than that in group M1[(3.853±0.249)ng/L vs(3.262±0.231)ng/L,P<0.05].but there was no significant difference between the group M2 and the group C[(3.323±0.232)ng/L vs(3.262±0.231)ng/L,P>0.05].3.2 Detection of Serum TGF-?Before treatment(T0),the levels of serum TNF-?in group C were significantly lower than those in group M1[(84.778±40.102)ng/L vs(274.728±43.095)ng/L,P<0.05]and in group M2[(84.778±40.102)ng/L vs(276.582±48.056)ng/L,P<0.05],but there was no significant difference between group M1 and group M2[(274.728±43.095)ng/L vs(276.582±48.056)ng/L,P>0.05].Six months later,the serum TNF-?level of patients in the T6 stage of group C decreased[(67.804±30.395)ng/L vs(84.778±40.102)ng/L,P<0.05].The serum TNF-?levels of the patients in the M1 and M2 groups also decreased[M1:(201.612±58.314)ng/L vs(274.728±43.095)ng/L,P<0.05;M2:(72.440±30.975)ng/L vs(276.582±48.056)ng/L,P<0.05],but the levels of TNF-?in the patients of M1 group and M2 group were still higher than those in the C group.[(201.612±58.314)ng/L vs(67.804±30.395)ng/L,P<0.05;(72.440±30.975)ng/L vs(67.804±30.395)ng/L,P<0.05];The serum levels of TNF-?decreased in both M1 and M2 groups,but the decrease of M2 group was more obvious,There was a significant difference compared with M1 group[(72.440±30.975)ng/L vs(201.612±58.314)ng/L),P<0.05].The serum TNF-?level of patients in group M1 and group M2 continued to decrease after standardized antituberculous therapy until 24 months after antituberculous therapy(T24),the level of serum TNF-?decreased[(56.339±31.883)ng/L vs(72.440±30.975)ng/L,P<0.05],while the serum TNF-?level in group M1 decreased[(143.081±65.947)ng/L vs(201.612±58.314)ng/L,P<0.05],compared with the level in group C,the level of serum TNF-?in group M1 was still high[(143.081±65.947)ng/L vs(54.321±31.066)ng/L,P<0.05],but there was no significant difference between group M2 and group C[(56.339±31.883)ng/L vs(54.321±31.066)ng/L,P>0.05].3.3 Detection of Serum IL-17Before treatment(T0),the serum IL-17 levels in group C were significantly lower than those in group M1[(39.258±2.909)ng/L vs(87.237±7.410)ng/L,P<0.05]and group M2[(39.258±2.909)ng/L vs(86.766±8.629)ng/L,P<0.05],while the serum IL-17 levels in group M1 were not significantly different from those in group M2[(87.237±7.410)ng/L vs(86.766±8.629)ng/L,P>0.05].After 6 months of standardized anti-tuberculosis treatment(T6),the serum IL-17 levels in group C decreased slightly[(31.954±3.786)ng/L vs(39.258±2.909)ng/L,P<0.05],there was no significant change in serum IL-17level in group M1[(87.435±8.764)ng/L vs(87.237±7.410)ng/L,P<0.05],while in group M2,the serum IL-17 decreased rapidly[(45.360±8.655)ng/L vs(86.766±8.629)ng/L,P<0.05],but the serum IL-17 level in group M2 was still higher than that in group C[(45.360±8.655)ng/L vs(31.954±3.786)ng/L,P<0.05].Because the content of M2 group decreased obviously,there were significant differences in serum IL-17 levels between group M1 and group M2[(45.360±8.655)ng/L vs(87.435±8.764)ng/L),P<0.05].The serum IL-17levels in group M1 and group M2 continued to be standardized until 24months after antituberculous therapy,the serum IL-17 levels in group M1decreased[(71.290±20.962)ng/L vs(87.435±8.764)ng/L,P<0.05],but compared with those in group C of T24,the serum IL-17 levels in M1 group was still high[(71.290±20.962)ng/L vs(31.941±8.964)ng/L,P<0.05],the serum IL-17 level in group M2 was further decreased[(32.867±6.268)ng/L vs(72.440±30.975)ng/L,P<0.05],but there was no significant difference between group M2 and group C[(32.867±6.268)ng/L vs(31.941±8.964)ng/L,P>0.05].3.4 Detection of Serum IL-22Before treatment(T0),the level of serum IL-22 in group M1 was significantly lower than that in group M1[(22.719±11.434)ng/L vs(225.010±64.792)ng/L,P<0.05]and group M2[(22.719±11.434)ng/L vs(221.133±52.444)ng/L,P<0.05],but the serum IL-22 level in M1 group was not significantly different from that in group M2[(225.010±64.792)ng/L vs(221.133±52.444)ng/L,P>0.05].6 Months later(T6),the serum IL-22 level of patients in group C decreased slightly[(22.793±10.855)ng/L vs(22.719±11.434)ng/L,P<0.05],The serum IL-22 levels in both M1 and M2groups were also decreased:[M1:(189.476±55.738)ng/L vs(225.010±64.792)ng/L,P<0.05;M2:(95.282±25.087)ng/L vs(221.133±52.444)ng/L,P<0.05],but the serum IL-22 levels in M1 and M2 groups were still higher than those in group C[(189.476±55.738)ng/L vs(22.793±10.855)ng/L,P<0.05;(95.282±25.087)ng/L vs(22.793±10.855)ng/L,P<0.05];Compared with M1 group,the serum IL-22 level in M2 group was significantly lower than that in M1 group[(95.282±25.087)ng/L vs(189.476±55.738)ng/L,P<0.05].M1 group and M2group continued to regulate antituberculotic therapy until 24 months(T24),the serum IL-22 level in M1 group decreased significantly[(42.136±21.257)ng/L vs(189.476±55.738)ng/L,P<0.05],but the level of serum IL-22 in group M1was still higher than that in group C at the same time[(42.136±21.257)ng/L vs(15.756±9.491)ng/L,P<0.05],while the level of serum IL-22 in group M2was significantly decreased[(19.626±8.089)ng/L vs(95.282±25.087)ng/L,P<0.05],and there was no significant difference between group M2 and group C[(19.626±8.089)ng/L vs(15.756±9.491)ng/L,P>0.05].Conclusion:1.The cytokines TNF-??IL-17 and IL-22 may be involved in the development of drug resistance of Mycobacterium tuberculosis,and they play an important role in the immune defense mechanism of MDR-TB;2.The adjuvant therapy of immunomodulation can improve the clinical therapeutic effect of multi-drug resistant pulmonary tuberculosis,which may be related to the immunoregulatory effect of TGF-?on the immunosupp ression of mdr-tb patients. |
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