Adjuvant Immunotherapy of Extensively Drug-Resistant Tuberculosis (XDR-TB) in Ukraine
Nathalia D. Prihoda,
Olga V. Arjanova,
Larisa V. Yurchenko,
Nina I. Sokolenko,
Lyudmila A. Vihrova,
Volodymyr S. Pylypchuk,
Valery M. Frolov
Galyna A. Kutsyna
Conventional TB chemotherapy success rates are very low in patients with Extensively Drug-Resistant Tuberculosis (XDR-TB). We treated twelve XDR-TB individuals, seven of which in addition to standard Anti-TB Therapy (ATT) received Immunoxel (Dzherelo), Svitanok and Lisorm over-the-counter herbal immunomodulators. All seven patients who received adjunct immunotherapy improved clinically and radiologically and were discharged after 3.7±0.8 months, with average/median time to mycobacterial clearance 28/25 days. None of five patients on TB drugs alone improved and one died. Patients on immune intervention gained 9.6 kg (p = 0.0001) while those on ATT lost 1.4 kg. The levels of total bilirubin decreased from 15.6 to 10.7 μmol L-1, similarly, the values of alanine transaminase (ALT) declined from abnormally high 42.6 IU L-1 to normal levels 22.9 IU L-1 (p = 0.23). Patients on ATT had unchanged levels of bilirubin, but their ALT declined from 29.6 to 12 IU L-1 (p = 0.02). The levels of hemoglobin rose from 104.1 to 118 g L-1 (p = 0.07) whereas leukocyte counts descended to normal levels from 8.9 to 7.3x109 cells L-1 (p = 0.003). Conversely, in patients on ATT leukocyte counts rose from 8.7 to 13.8x109 cells L-1 (p = 0.21), whereas hemoglobin declined to below normal levels from 116.4 to 96.6 g L-1 (p = 0.18). These results show that immune-modulating interventions can favorably influence the effect of TB drugs. The difference between two treatment outcomes was highly significant (Mantel Haenszel odds ratio = 11; p = 0.0009 at 95% CI). Thus, adjunct herbal immunotherapy is safe, shortens treatment duration and can overcome drug resistance even in patients with XDR-TB.
to cite this article:
Nathalia D. Prihoda, Olga V. Arjanova, Larisa V. Yurchenko, Nina I. Sokolenko, Lyudmila A. Vihrova, Volodymyr S. Pylypchuk, Valery M. Frolov and Galyna A. Kutsyna, 2009. Adjuvant Immunotherapy of Extensively Drug-Resistant Tuberculosis (XDR-TB) in Ukraine. Current Research in Tuberculosis, 1: 9-14.
The extensively resistant TB (XDR-TB) is diagnosed when M. tuberculosis
bacilli in addition to lack of sensitivity to isoniazid (H) and rifampicin (R),
two most commonly-used, first-line TB drugs, are also resistant to any one of
fluoroquinolones and of second-line injectable drugs, e.g., capreomycin, kanamycin
and amikacin (Migliori et al., 2008). This emerging form of TB caused
worldwide concern after outbreak in Kwazulu Natal Province of South Africa where
52 of 53 patients with XDR tuberculosis and HIV co-infection died within 2 weeks
of the time of diagnosis (Gandhi et al., 2006). Success rates in treating
XDR-TB are significantly lower than among drug-sensitive cases ranging between
29 and 67%. In addition, it takes much longer (18-24 months) to achieve a cure
and concerns over adverse effects of drugs became more prominent since second-line
drugs are more toxic. The cost is another factor as the deployment of second-line
drugs increases treatment cost by about hundred-fold. Clearly, there is an urgent
need to find additional therapeutic interventions that could overcome these
Immunomodulators Immunoxel (Dzherelo), Svitanok and Lizorm are made from a proprietary combination of medicinal plants and are commonly used in Ukraine for the management of TB and HIV infections, including patients with dual infection (Arjanova et al., 2009; Chechitiany et al., 2007; Melnik et al., 1999; Nikolaeva et al., 2008; Prihoda et al., 2007; Zaitzeva et al., 2008). They have been approved in 1997 by the Ministry of Health of Ukraine as functional supplements with therapeutic indications. Dzherelo and Svitanok were specifically recommended as immune adjuvants to the therapy of pulmonary tuberculosis (Melnik et al., 1999). So far, the phytoconcentrates we have decided to use in this study have been taken safely by several hundred thousand individuals for various indications including chronic bacterial and viral infections such as TB and HIV, autoimmune diseases and malignancy (Chkhetiany et al., 2007). In this retrospective study, conducted at Lisichansk TB Dispensary, we have compared the adjunct effect of herbal immunomodulators to outcome of treatment with conventional TB therapy.
MATERIALS AND METHODS
Lisichansk TB Dispensary is within Luhansk administrative region of the
Eastern Ukraine with total population 2.5 million. Approximate population of
registered TB patients in this region is 2000. Lisichansk TB dispensary has
turnover of about 600-800 patients per year. The dispensary has six medical
doctors and approximately 15 medical nurses and lab technicians who care for
hospitalized patients and perform the lab work.
Twelve patients with pulmonary XDR-TB were identified retrospectively, five who received individualized TB drugs regimen and seven who received in addition to ATT a combination of immunomodulating phytopreparations Dzherelo, Svitanok and Lizorm. All patients were males with age range between 25 and 67 years. Five presented with first-diagnosed TB and the rest were previously treated, relapsed cases of TB. All study patients presented with acute symptoms of pulmonary TB that required hospitalization. Most common symptoms were prolonged heavy cough, pain in the chest, high fever, profuse night sweats, fatigue and loss of weight and appetite. Active pulmonary tuberculosis was certified by a medical history and clinical findings compatible with tuberculosis, a chest X-ray showing lung involvement and positive sputum smear for Acid-Fast Bacilli (AFB) and the culture of M. tuberculosis. The conduct of the study was approved by the Internal Review Board (IRB) of Lisichansk TB dispensary in accordance with the Helsinki Declaration.
All anti-TB drugs were procured free-of-charge through the centralized national
supply system of Ukraine. The over-the-counter phytoconcentrates, Dzherelo,
Lizorm and Svitanok were generously supplied by Ekomed LLC. Individualized,
first- and second-line anti-TB drugs were administered to all hospitalized patients
based on physicians decision prior to or after results of drug susceptibility
tests. In the immunotherapy group, in addition to ATT, patients received a daily
dose of Dzherelo which was given as 30 drops diluted in a half-glass of water
30 min before breakfast. Some patients received Immunoxel, a slightly modified
form of Dzherelo. The same dose, 30 drops, of Lizorm and Svitanok were given
before lunch and supper, respectively. The exact formula of phytoconcentrates
has been described by Prihoda et al. (2008). Sputum smear and culture
examinations for AFB were performed at monthly intervals. The decision to discharge
was based on at least twice-repeated negative culture outcome and satisfactory
clinical and radiological findings.
TB Drug Resistance Testing
The drug resistance to first- and second-line TB drugs was tested with commercially
supplied kits (Tulip Diagnostics, Goa, India). The cultures of M. tuberculosis
derived from sputum of each patient were inoculated into ready-to-use tubes
containing TB drugs incorporated at manufacturer-predetermined concentrations
into standard Löwenstein-Jensen agar slants. The cultures were incubated
at 37°C and checked periodically until appearance of colonies in control
tubes without drugs. The calculation of the proportion of resistant bacilli
was done by comparing counts on drug free and drug-containing Löwenstein-Jensen
The obtained results were analyzed with available online statistical software
(GraphPad Software, Inc., La Jolla, CA). All statistical analysis were done
on intent-to-treat basis, involving the total number of patients without subgrouping
them into responders and non-responders. The stratification analysis of patients
was conducted to reveal the difference between distinct treatment categories.
Parametric baseline values relative to the end of study values were evaluated
by paired or unpaired Student t-test. The categorical test was done by Mantel
Haenszels odds ratio calculation. The probability values were considered
as significant at p≤0.05 cut-off value.
RESULTS AND DISCUSSION
None of five patients on conventional TB drugs regimen had positive outcome after 9 months of treatment and one patient died after 9.5 months. The duration of treatment in the immunotherapy group ranged between 10.6-20.4 weeks with average/median 15.7/16.7 weeks (Table 1). The treatment lasted until patients were discharged from the dispensary upon twice-repeated negative culture findings and clinical and radiological improvements. The time to negative culture conversion ranged between 20-37 days with mean/median 28/25 days. Mycobacterial clearance was confirmed by repeated cultures at monthly intervals.
There appears to be no difference between first-diagnosed TB cases versus chronic, previously treated TB in terms of median days to discharge, i.e., 117 vs. 105.6, or days to mycobacterial clearance, 23 vs. 30. However, sample size was too small to reveal statistically significant difference.
At the end of the study every patient in the immunatherapy group had gained substantial lean body mass ranging between 6 and 13 kg. The average accrual in lean body mass was 9.6 kg, which was statistically highly significant as evidenced by a paired Students t-test (p = 0.0001) m-dash an effect that was evident as early as one month from initiation of the therapy. In contrast, patients on ATT had lost on average 1.4 kg (p = 0.4).
The potential hepatotoxicity of ATT combination with herbal preparations was monitored by quantitative liver function tests. Surprisingly, despite intensive chemotherapy, patients have shown signs of better liver function. The level of total bilirubin had decreased from mean 15.6 to 10.7 μmol L-1 em-dash favorable change that was not statistically significant (p = 0.16). Similarly, the values of alanine transaminase (ALT), another marker of liver damage, declined from abnormally high (42.6 IU L-1) to normal levels (22. IU L-1) em-dash change that was not statistically significant (p = 0.23). Patients on ATT had same levels of bilirubin but their ALT declined from 29.6 to 12 IU L-1 (p = 0.02).
Another phenomenon observed during therapy is a reversal of baseline anemic
state and pro-inflammatory condition em-dash symptoms very common in TB. Most
patients at study entry displayed signs of anemia and had abnormally elevated
leukocyte counts. At the end of treatment these parameters were improved in
a statistically significant manner. The levels of hemoglobin had risen from
104.1 to 118 g L-1 (p = 0.07), whereas leukocyte counts descended
to quasi-normal levels from 8.9 to 7.3x109 cells L-1 (p
= 0.003). In patients on ATT the reverse trend was observed. Leukocyte counts
had risen from 8.7 to 13.8x109 cells L-1 (p = 0.21) whereas
hemoglobin declined to below normal levels from 116.4 to 96.6 g L-1
(p = 0.18).
||Baseline and outcome characteristics of XDR-TB patients treated
with TB drugs without or in combination with Dzherelo (Immunoxel), Svitanok
|aCriteria for definition of XDR are as per the
WHO recommendations. TB drugs are H: Isoniazid, R: Rifampicin, Z: Pyrazinamide,
E: Ethambutol, S: Streptomycin, L: Levofloxacin, O: Ofloxacin, C: Ciprofloxacin,
P: Pefloxacin, K: Kanamycin, A: Amikacin, Cs (Cycloserine), PAS: Para-aminosalicylic
acid, Eth: Ethionamide, Proth: Prothionamide, RFB: Rifabutin, Dzherelo:
Dzh, Svitanok: Sv, Lizorm: Li
These results show that immune-modulating interventions can favorably influence the efficacy of TB drugs (Arjanova et al., 2009; Chkhetiany et al., 2007; Nikolaeva et al., 2008; Prihoda et al., 2007; Zaitzeva, 2008). All seven patients who received ATT and immunotherapy improved clinically and radiologically and were discharged after 3.7±0.8 months, with average/median time to mycobacterial clearance 28/25 days. None of five patients on TB drugs alone improved and one had died. The difference between two treatment outcomes was statistically significant (Mantel Haenszel odds ratio = 11; p = 0.0009 at 95% CI).
Present results compare favorably to XDR-TB chemotherapy outcomes reported in several recent papers. According to study by Kim et al. (2008) only 29.3% of those with XDR-TB were cured. TB therapy success rate in Russian patients with XDR-TB as reported by Keshavjee et al. (2008) was 48.3%. Earlier reported cure rates in Europe, USA, Peru and Korea were between 37.5-67% indicating that XDR-TB poses serious clinical challenge (Edward et al., 2008; Kwon et al., 2008; Migliori et al., 2008; Mitnick et al., 2008). In conclusion, adjunct herbal immunotherapy is safe, enhances significantly treatment outcome and can overcome drug resistance even in patients with extremely poor prognosis. Further studies are needed to confirm present findings.
We thank all participants who volunteered in this study. The support of clinical staff and technicians who contributed to this study has been of tremendous help to us. We are grateful to other colleagues who shared their insight and provided helpful suggestions based on their own experience with phytoconcentrates used in present study.
Arjanova, O.V., N.D. Prihoda, N.I. Sokolenko, L.V. Yurchenko, L.A. Vihrova, V.S. Pylypchuk, V.M. Frolov and G.A. Kutsyna, 2009. Impact of adjunct immunotherapy with multi-herbal supplement Dzherelo (Immunoxel) on treatment outcomes in end-stage TB/HIV patients. J. Appl. Res. Clin. Exp. Ther.
Chechitiany, R., V. Pylypchuk, O. Argzanova, N. Prihoda, L. Vichrova, E. Zagaydanova and G. Kutsyna, 2007. Comparative effect of an immunomodulator immunoxel (Dzherelo) when used alone or in combination with antiretroviral therapy in drug-naÔve HIV infected individuals. Int. J. Biotechnol., 9: 267-276.
Direct Link |
Edward, D., E.D. Chan M.J. Strand and M.D. Iseman, 2008. Treatment outcomes in extensively resistant tuberculosis. New Engl. J. Med., 359: 657-659.
Direct Link |
Gandhi, N.R., A. Moll, A.W. Sturm, R. Pawinski and T. Govender et al., 2006. Extensively drug-resistant tuberculosis as a cause of death in patients co-infected with tuberculosis and HIV in a rural area of South Africa. Lancet, 368: 1575-1580.
Direct Link |
Keshavjee, S., I.Y. Gelmanova, P.E. Farmer, S.P. Mishustin and A.K. Strelis et al., 2008. Treatment of extensively drug-resistant tuberculosis in Tomsk, Russia: A retrospective cohort study. Lancet, 372: 1403-1409.
Direct Link |
Kim, D.H., H.J. Kim, S.K. Park, S.J. Kong and Y.S. Kim et al., 2008. Treatment outcomes and long-term survival in patients with extensively drug-resistant tuberculosis. Am. J. Respir. Crit. Care Med., 178: 1075-1082.
Direct Link |
Kwon, Y.S., Y.H. Kim, G.Y. Suh, M.P. Chung and H. Kim et al., 2008. Treatment outcomes for HIV-uninfected patients with multidrug-resistant and extensively drug-resistant tuberculosis. Clin. Infect. Dis., 47: 496-502.
Direct Link |
Melnik, V.P., O.V. Panasyuk, V.S. Pylypchuk, O.P. Moshich, N.M. Procenko and O.M. Leonenko, 1999. Deployment of herbal preparations Dzherelo and Svitanok for combination therapy of pulmonary tuberculosis. Medical Institute of Ukrainian Association of Peopleís Medicine. Information Bulletin of the Ministry of Health of Autonomous Republic of Crimea. UDK:616.24-002.5-085-038:615.017. 1999. Kiev, Ukraine.
Migliori, G.B., C. Lange, R. Centis, G. Sotgiu and R. Mutterlein et al., 2008. TBNET Study Group. Resistance to second-line injectables and treatment outcomes in multidrug-resistant and extensively drug-resistant tuberculosis cases. Eur. Respir. J., 31: 1155-1159.
Direct Link |
Mitnick, C.D., S.S. Shin, K.J. Seung, M.L. Rich and S.S. Atwood et al., 2008. Comprehensive treatment of extensively drug-resistant tuberculosis. New Engl. J. Med., 563: 563-574.
Direct Link |
Nikolaeva, L.G., T.V. Maystat, V.S. Pylypchuk, Y.L. Volyanskii, L.A. Masyuk and G.A. Kutsyna, 2008. Effect of oral immunomodulator Dzherelo (Immunoxel) in TB/HIV co-infected patients receiving anti-tuberculosis therapy under DOTS. Intl. Immunopharmacol., 8: 845-851.
Prihoda, N.D., O.V. Arjanova, L.V. Yurchenko, N.I. Sokolenko, L.A. Vihrova, V.S. Pylypchuk and G.A. Kutsyna, 2007. Open label trial of adjuvant immunotherapy with Dzherelo, Svitanok and Lizorm, in MDR-TB, XDR-TB and TB/HIV co-infected patients receiving anti-tuberculosis therapy under DOT. J. Med. Plant Res., 1: 117-122.
Direct Link |
Prihoda, N.D., O.V. Arjanova, L.V. Yurchenko, N.I. Sokolenko, L.A. Vihrova, V.S. Pylypchuk and G.A. Kutsyna, 2008. Adjunct immunotherapy of tuberculosis in drug-resistant TB and TB/HIV co-infected patients. Int. J. Biomed. Pharm. Sci., 2: 59-64.
Direct Link |
Zaitzeva, S.I., S.L. Matveeva, T.G. Gerasimova, Y.N. Pashkov, D.A. Butov, V.S. Pylypchuk V.M. Frolov and G.A. Kutsyna, 2008. Efficacy and safety of phytoconcentrate Dzherelo (Immunoxel) in treatment of patients with multi-drug resistant TB (MDR-TB) in comparison to standard chemotherapy. Res. J. Med. Sci.