1. Levels of IL-18, sCD14, CCL2, CXCL8 and CXCL10 in tubercular immune reconstitution inflammatory syndrome in a North Indian population Manoj Kumar 1, Patricia Price 3, Manisha Jain 1, Ben Oliver 3, Amitabh Kumar 2, Upasna Agrawal 2, Sarman Singh 1 1. Department of Laboratory Medicine, All India Institute of Medical Sciences, India. 2. LRS Institute of TB & Respiratory Diseases, New Delhi, India. 3. School of Pathology & Laboratory Medicine, University of Western Australia, Australia Abstract Number: 11497 (WEPDA204)

2. Introduction Some HIV-TB co-infected patients on ATT develop worsening of signs and symptoms of tuberculosis during the initial months of ART. This is termed paradoxical Immune Reconstitution Inflammatory Syndrome (IRIS). IRIS frequency is variable and its immunopathogenesis is poorly understood. Objectives  To determine the frequency, risk factors and outcome of mycobacterial IRIS in Indian patients co-infected with HIV/TB and receiving ATT and ART.  ELISA studies of cytokines, chemokines and antibodies relevant to IRIS

3. Material and Methods Recruitment of Patients, n=62 (Aug 2007-April 2009) Recruitment of Patients, n=62 (Aug 2007-April 2009) Host genetic polymorphism study (now underway) Host genetic polymorphism study (now underway) Immunological assays using ELISA Immunological assays using ELISA

4. Demographics and Baseline Characteristics of patients 62 patients were followed for 6 months IRIS (n=19) Non-IRIS (n=43) papa PTB5 (26%)18 (42%)0.20 EPTB12 (63%)16 (37%)0.20 PTB + EPTB2 (11%)9 (21%)0.40 % of cohort31%69% Patient age (years) 36 (25-50)35 (18-65)0.69 Male 16 (84%)34 (79%) 0.78 Died 7 (37%) b 6 (14%)0.09 CD4 T-cells/ul at start of ART 78 (14-189)100 (2-198) 0.56 CD4 T-cells/ul at 6 months 181 (46-582)125 (59-664) 0.13 ATT before ART (days) 28 (5-117)27 (7-255) 0.55 ART before IRIS (days) 17 (5-153) NA- a Mann Whitney U test (continuous variables) or Fisher’s test (categorical variables) b 4 patients with TB Meningitis as IRD, all died; NA, not applicable

5. sCD14 plasma levels were marginally higher at the IRIS event compared to baseline. Levels did not change in patients without IRIS. Elevated IL-18 and sCD14 suggest monocytes contribute to IRIS Plasma IL-18 levels were higher at the IRIS event than baseline (p=0.05). Levels did not change in Non-IRIS patients. p = 0.73p = 0.05 p = 0.23 p = 0.47 p = 0.54 p = 0.06 p = 0.14 p = 0.32

6. Low plasma levels of CCL2 and CXCL8 may predispose a patient to IRIS CCL2 levels were lower in IRIS patients than non-IRIS patients at baseline (p=0.03). CCL2 levels did not rise on ART in any patients. CXCL8 levels were marginally lower in IRIS patients at baseline CXCL8 levels increased on ART in non-IRIS patients (p=0.02). p = 0.08 p = 0.02 p = 0.15 p = 0.13 CXCL8 Concentration (pg/ml) p = 0.23 p = 0.63 p = 0.03 p =0.34 IRIS Week 0 IRIS Time Non-IRIS week 0 Non-IRIS week4 1 10 100 1000 10000 100000 CCL2 Concentration (pg/ml)

7. Low plasma levels of CXCL10 also may predispose a patient to IRIS p = 0.43 p =0.05 p = 0.91 p = 0.08 Rise in CXCL10 levels was found in both IRIS and non-IRIS patients on therapy. But baseline levels predicted IRIS (p=0.05).

8. Discussion & Conclusions  Paradoxical TB IRIS is relatively common, affecting 31% of patients in a TB clinic in India.  IRIS and non-IRIS patients were similar in age, baseline CD4 T- cell counts, CD4 T-cell recovery and duration of ATT before ART.  The increased levels of IL-18 and sCD14 in paradoxical TB IRIS suggest a role for the monocyte response to bacterial motifs.  Low levels of chemokines at baseline may also promote paradoxical TB IRIS – perhaps by impairing mycobacterial clearance. These molecules should be investigated as prognostic markers.

9. Acknowledgement AIIMS, New Delhi, India Prof. Sarman Singh Manisha Jain LRS, New Delhi, India Dr. Upasna Agrawal Dr. Amitabh Kumar Dr. Jyoti Sharma Mrs. Komal Sharma Mrs. Meenakshi Arjun & SatPal UWA, Perth, Australia Prof. Patricia Price Dr. Martyn French Ben Oliver Jacquita Affendi Sara Tanskovic I would like to express my gratitude to all lab colleagues & all my patients who participated in the study. Left to right: Dr. Amitabh Kumar, Prof. Patricia Price, Prof. Sarman Singh, Mr. Manoj Kumar, Dr. Upasna Agrawal