Co-infection of tuberculosis and parasitic diseases in humans: a systematic review

  • Xin-Xu Li1, 2 and

    Affiliated with

    • Xiao-Nong Zhou1Email author

      Affiliated with

      Parasites & Vectors20136:79

      DOI: 10.1186/1756-3305-6-79

      Received: 4 January 2013

      Accepted: 18 March 2013

      Published: 22 March 2013

      Abstract

      Co-infection of tuberculosis and parasitic diseases in humans is an important public problem in co-endemic areas in developing countries. However, there is a paucity of studies on co-infection and even fewer reviews. This review examines 44 appropriate papers by PRISMA from 289 papers searched in PubMed via the NCBI Entrez system (no grey literature) up to December 2012 in order to analyze the factors that influence epidemic and host’s immunity of co-infection. The limited evidence in this review indicates that most common parasite species are concurrent with Mycobacterium tuberculosis in multiple organs; socio-demographics such as gender and age, special populations with susceptibility such as renal transplant recipients, patients on maintenance haemodialysis, HIV positive patients and migrants, and living in or coming from co-endemic areas are all likely to have an impact on co-infection. Pulmonary tuberculosis and parasitic diseases were shown to be risk factors for each other. Co-infection may significantly inhibit the host’s immune system, increase antibacterial therapy intolerance and be detrimental to the prognosis of the disease; in addition, infection with parasitic diseases can alter the protective immune response to Bacillus Calmette-Guerin vaccination against Mycobacterium tuberculosis.

      Keywords

      Tuberculosis Parasitic diseases Co-infection

      Introduction

      Rationale

      Both tuberculosis (TB) and parasitic diseases in humans are infectious diseases that exhibit an extensive distribution, causing serious harm to humans. The World Health Organization Special Programme for Research and Training in Tropical Diseases (WHO TDR) provided the TDR disease portfolio in 1999 to deal with the deterioration in the health situation, including leprosy, TB and eight kinds of parasitic diseases, such as malaria, schistosomiasis, etc. [1]. WHO estimated that there was about one third of the global population infected by TB, and in 2010, there were an estimated 8.8 million incident cases of TB globally, mostly occurring in Asia (59%) and Africa (26%) [2]. Meanwhile, in 2009 WHO also reported that there were an estimated 225 million malaria cases, mainly distributed in Africa (78%), South-East Asia (15%) and the Eastern Mediterranean (5%) [3]. In 2012, there were an estimated 436 million people at risk of Schistosomiasis haematobium infection in Sub-Saharan Africa, of which 112 million were infected, with an estimated 393 million people at risk of Schistosomiasis mansoni infection, of which 54 million were infected [4]; an estimated 120 million people in tropical and subtropical areas of the world were infected with lymphatic filariasis in 2009 [5]. These figures suggest that there is an overlap of endemic regions between TB and parasitic disease, which may lead to co-infection of these diseases in the population.

      The earliest report we found was from 1945 and interpreted how to treat a pulmonary TB (PTB) case running concurrently with malaria [6]. A report from 1946 described co-existence of TB with hookworm [7]. The co-infection of TB and parasitic diseases have been reported in many studies for almost the past 70 years, although great achievements have been gained in the fields of TB and parasitic disease control and prevention respectively [25]. Up to 2012, some cases of co-infection between TB and parasitic diseases were reported around the world [829], and some epidemiological surveys of co-infection in hospitals or communities were carried out [3034]. Some of these studies showed that the immune response was modified in the co-infection situation [3551].

      Inevitably, co-infection would increase the complexity of control and prevention on TB and parasitic diseases. The current systematic reviews on the co-infection of TB and parasitic diseases help to clarify the complexity of co-infections; however, there are only a few systematic reviews on co-infection. We only found that Enwere et al.[35] reviewed the host response of co-infection between TB and malaria and 4 reviews focused on the influence of chronic helminth infections on immunity against TB [44, 45, 47, 48].

      Objectives

      This paper reviewed studies globally over the past 70 years on the co-infection of TB and parasitic diseases using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [52], in order to learn more about which parasites are concurrent with TB, the epidemiological situation regarding co-infection, and the human immune function affected by co-infection.

      Methods

      Protocol and registration

      We did not register the protocol for this review.

      Eligibility criteria

      Published articles were included if they involved case reports of co-infection with TB and any parasitic diseases in human participants, or epidemiological surveys of co-infection in populations, or clinical or laboratory research on the immune responses during co-infection, were eligible for inclusion in the systematic review. Journal articles published with full text or abstracts in English before 2013 were eligible for inclusion.

      Information sources

      We mainly searched PubMed via the NCBI Entrez system (any date to December, 2012) (http://​www.​ncbi.​nlm.​nih.​gov) for studies on the association between TB and parasitic diseases. We also searched bibliographies of identified reports, including previous reviews, for additional references.

      Search

      The search was limited to studies of human beings or animal models and no language limits were applied. The terms that were used as MeSH terms or Direct keywords for the search and our search strategy are described in Table 1. All titles, abstracts and full texts from each of the searches were examined and reviewed.
      Table 1

      Search strategy and terms used to identify studies on co-infection between TB and common parasitic diseases

      Term

      1. tuberculosis, 2. parasite, 3. helminth, 4. amoebiasis, 5. leishmaniasis, 6. trypanosomiasis, 7. giardiasis, 8. trichomoniasis, 9. malaria, 10. toxoplasmosis, 11. cryptosporidiosis, 12. clonorchiasis, 13. opisthorchiasis, 14. fasciolopsiasis, 15. fascioliasis, 16. paragonimiasis, 17. schistosomiasis, 18. sparganosis, 19. echinococcosis, 20. ascariasis, 21. trichuriasis, 22. enterobiasis, 23. hookworm, 24. strongyloidiasis, 25. trichinellosis, 26. filariasis, 27. dracunculiasis

      Strategy

      1 and (2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27)

      Study selection

      The study selection process is illustrated in Figure 1.
      http://static-content.springer.com/image/art%3A10.1186%2F1756-3305-6-79/MediaObjects/13071_2013_Article_857_Fig1_HTML.jpg
      Figure 1

      Study selection information regarding co-infection between TB and parasitic diseases.

      Papers that were not co-infection studies, or were not for humans, or were published in non-English language without an abstract in English, were excluded. Eligible papers were tabulated.

      Data collection process

      Two reviewers extracted data from each eligible study independently, and differences were resolved by discussion with a third. Extracted data was tabulated on the basis of data items. No formal meta-analysis was carried out and analysis to investigate statistical heterogeneity or publication bias was not performed because most of the studies were case reports and immunological research, and there were very few epidemiological surveys.

      Data items

      Data extracted included country, year, co-infection of diseases, sex, age, human immunodeficiency virus (HIV) test and medical history for case reports. For epidemiological surveys, the detailed information included was country, year, survey site, number of population screened, number of people with PTB, number of people with parasitic disease, number of people co-infected and prevalence. For clinical or laboratory research on immunity during co-infection, we collected detailed information on country, year, co-infection of disease, subject and conclusions.

      Summary measures

      Risk ratios (RR) and their 95% confidence intervals (CI) were calculated using the Statistical Analysis System (SAS 9.2; SAS Institute Inc., Cary, NC, USA) through Chi square test. All P-values of <0.05 were taken as statistically significant.

      Results

      Two hundred and eighty nine papers were retrieved from the search of published work, of which, 10 were excluded because of duplication and 235 were irrelevant to co-infection with TB and parasitic diseases. Finally, 44 studies of co-infection were included in the analysis, of which, 22 were case reports, 5 were epidemiological surveys and 17 were immunological research/reviews (Figure). There was no grey literature included.

      Table 2 summarizes the case reports of co-infection. Twenty-four cases were reported in 22 studies from 13 countries during 1984 to 2012, in which 7 cases were from India. Fourteen studies investigated co-infection with PTB and parasites diseases and 8 studies involved the extrapulmonary TB, such as renal TB, lymph node TB, abdominal TB, TB in liver, tuberculous lymphadenitis and TB verrucosa cutis. The youngest case reported was 34 days old and the eldest case was 82 years old, and the median age of all cases reported was 36 years old. Fifteen of a total 24 cases were male. Ten patients with different clinical conditions co-infected with TB and leishmaniasis were reported, of which, visceral leishmaniasis was the highest. There were also 6 cases co-infected with TB and hydatid disease. In addition, parasitic diseases accompanied by TB included trichomoniasis, malaria, toxoplasmosis, toxocariasis, schistosomiasis, strongyloidiasis and filarial elephantiasis in different organs. Fourteen of a total of 24 cases reported had been tested for HIV test and 4 were positive.
      Table 2

      Case reports of co-infection between TB and parasitic diseases

      Country

      Year of report

      Tuberculosis

      Parasitic disease

      Sex

      Age

      HIV test

      Supplement

      No. of reference

      Spain

      1996

      Renal TB

      Visceral leishmaniasis

      Male

      44 years

      Negative

      Haemodialysis for 19 months

      [8]

      Brazil

      2001

      PTB

      Visceral leishmaniasis

      Male

      29 years

      Negative

      Pneumocystis carinii positive

      [9]

      Turkey

      2003

      PTB

      Visceral leishmaniasis

      Male

      39 years

      Negative

      Renal transplantation in 2001; Anti-HCV and HCV RNA positive

      [10]

      India

      2005

      PTB

      Visceral leishmaniasis

      Male

      37 years

      Positive

      Tuberculoma of brain

      [11]

      India

      2006

      PTB

      Visceral leishmaniasis

      Female

      40 years

      Positive

       

      [12]

      India

      2006

      PTB

      Visceral leishmaniasis

      Male

      40 years

      Positive

       

      [12]

      Colombia

      1996

      PTB

      Mucocutaneous leishmaniasis

      Male

      50 years

      Negative

       

      [13]

      France

      2003

      PTB

      Cutaneous leishmaniasis

      Male

      44 years

      Negative

      A migrant from Brazil; Polar lepromatous leprosy

      [14]

      Sri Lanka

      2010

      Extrapulmonary TB

      Mucosal leishmaniasis

      Male

      52 years

      Negative

      T-lymphocyte subsets: CD3-437, CD4-237, CD8-146 μl; Serum IgG-532 and IgM-36 mg/dl

      [15]

      India

      2010

      PTB

      Post-kala-azar dermal leishmaniasis

      Female

      25 years

      Positive

      On treatment for leprosy and PTB for the past 2 months

      [16]

      France

      2000

      Lymph node TB

      Lymph node trichomoniasis

      Female

      82 years

      Negative

       

      [17]

      India

      2010

      PTB

      Perinatal falciparum malaria

      Female

      34 days

      Unknown

      Maternal history of falciparum malaria during eighth month of pregnancy; Father was smear-positive PTB case.

      [18]

      Haiti

      1984

      PTB

      Toxoplasmosis

      Male

      27 years

      Unknown

      Toxoplasmosis proved fatal and was diagnosed only at autopsy.

      [19]

      Sri Lanka

      2011

      Lymph node TB

      Toxoplasmosis Toxocariasis

      Male

      4 years

      Negative

       

      [20]

      Korea

      2012

      Disseminated TB

      Cerebral toxoplasmosis

      Male

      24 years

      Unknown

      A non-Korean engineer with abdominal TB

      [21]

      Australia

      2001

      PTB Tuberculous lymphadenitis

      Hepatosplenic schistosomiasis

      Male

      30 years

       

      A migrant from the Philippines; A history of alcohol abuse

      [22]

      India

      1991

      PTB

      Hydatid disease

      Female

      5 years

      Unknown

       

      [23]

      Turkey

      2002

      PTB

      Cardiac hydatid cyst

      Female

      52 years

      Negative

       

      [24]

      China

      2004

      TB in liver and abdominal cavity

      Liver multiple hydatidosis

      Female

      28 years

      Negative

       

      [25]

      Sudan

      2009

      PTB

      Hydatid disease

      Female

      25 years

      Unknown

      In a solitary pulmonary nodule of left lower lobe

      [26]

      China

      2009

      PTB

      Liver echinococcosis

      Male

      18 years

      Unknown

      PTB was previously confirmed in 2000 and found relapse in 2008.

      [27]

      China

      2009

      PTB

      Liver echinococcosis

      Female

      36 years

      Unknown

      PTB was previously confirmed in 1998 and found relapse in 2008.

      [27]

      Britain

      1994

      PTB

      Strongyloidiasis Giardiasis

      Male

      31 years

      Unknown

      A migrant from Gambia; Being resident in the United Kingdom for two years

      [28]

      India

      2001

      TB verrucosa cutis

      Filarial elephantiasis

      Male

      55 years

      Unknown

       

      [29]

      Abbreviations: HIV = human immunodeficiency virus; PTB = pulmonary tuberculosis; HCV = hepatitis C virus; RNA = ribonucleic acid; CD = cluster of differentiation; Ig = immunoglobulin.

      It can be seen in Table 3 that 5 studies from 3 East African countries and 1 East Asian country were conducted for epidemiology of co-infection between TB and parasitic diseases during 1984 to 2012. Two studies screened across the general population with 382 and 782 participants in a community and a hospital respectively, one study showed 329 and 215 PTB patients in two hospitals respectively, one study showed 309 PTB patients who were HIV positive and 346 who were HIV negative in a hospital, in the other study, there were 112 smear positive TB patients in a town, whose parasite species involved Entamoeba histolytica, Leishmania donovani, Giardia lamblia, malaria, Clonorchis sinensis, Schistosoma mansoni, taenia species, Ascaris lumbricoides, Trichocephalus trichiurus, hookworm and Strongyloides stercoralis. The prevalence of co-infection between TB and parasitic diseases varied widely among different participants, s species or survey sites.
      Table 3

      Epidemiological surveys of co-infection between TB and parasitic diseases

      Country

      Year of report

      No. of population screened (a)

      No. of people with TB (b)

      People with parasitic disease (c)

      No. of people co-infected (d)

      Prevalence (%)

      Survey site

      HIV test

      No. of reference

          

      No.

      Species

       

      d/a

      d/b

      d/c

         

      Korea

      1984

       

      329

       

      Trichocephalus trichiurus

      68

       

      20.7

       

      Hospital1

      Unknown

      [30]

         

      215

       

      Trichocephalus trichiurus

      14

       

      6.5

       

      Hospital2

      Unknown

       
         

      329

       

      Clonorchis sinensis

      58

       

      17.6

       

      Hospital1

      Unknown

       
         

      215

       

      Clonorchis sinensis

      13

       

      6.0

       

      Hospital2

      Unknown

       

      Sudan

      2004

      382

      100

      252

      Leishmania donovani

      77

      20.2

      77.0

      30.6

      Community

      Unknown

      [31]

      Ethiopia

      2006

      782

      100

      234

      Intestinal parasites

      32

      4.1

      32.0

      13.7

      Hospital

      Unknown

      [32]

        

      782

      100

      155

      Helminths

      16

      2.0

      16.0

      10.3

      Hospital

      Unknown

       
           

      Parasites species

             
        

      782

      100

      88

      Ascaris lumbricoides

      5

      0.6

      5.0

      5.7

      Hospital

      Unknown

       
        

      782

      100

      70

      Giardia lamblia

      15

      1.9

      15.0

      21.4

      Hospital

      Unknown

       
        

      782

      100

      50

      Entamoeba histolytica

      10

      1.3

      10.0

      20.0

      Hospital

      Unknown

       
        

      782

      100

      36

      Hookworm

      6

      0.8

      6.0

      16.7

      Hospital

      Unknown

       
        

      782

      100

      25

      Taenia species

      2

      0.3

      2.0

      8.0

      Hospital

      Unknown

       
        

      782

      100

      13

      Strongyloides stercoralis

      5

      0.6

      5.0

      38.5

      Hospital

      Unknown

       
        

      782

      100

      8

      Trichuris trichiura

      1

      0.1

      1.0

      12.5

      Hospital

      Unknown

       

      Tanzania

      2007

       

      309

       

      Malaria

      19

       

      6.1

       

      Hospital

      HIV positive

      [33]

         

      309

       

      Schistosomiasis

      100

       

      32.4

       

      Hospital

      HIV positive

       
         

      309

       

      Hookworm

      33

       

      10.7

       

      Hospital

      HIV positive

       
         

      346

       

      Malaria

      9

       

      2.6

       

      Hospital

      HIV negative

       
         

      346

       

      Schistosomiasis

      132

       

      38.2

       

      Hospital

      HIV negative

       
         

      346

       

      Hookworm

      86

       

      24.9

       

      Hospital

      HIV negative

       

      Ethiopia

      2012

       

      112

       

      Intestinal helminths

      32

       

      28.6

       

      Community

      47% (53/112) of PTB patients were HIV positive

      [34]

         

      112

       

      Ascaris lumbricoides

      12

       

      10.7

       

      Community

       
         

      112

       

      Hookworm

      8

       

      7.1

       

      Community

       
         

      112

       

      Schistosoma mansoni

      6

       

      5.4

       

      Community

       
         

      112

       

      Trichuris trichiura

      8

       

      7.1

       

      Community

       
         

      112

       

      Strongyloides stercoralis

      3

       

      2.7

       

      Community

       
      The interrelationship of infection with TB and parasitic diseases have been evaluated in Table 4 through two studies screened in the general population, with 382 and 782 participants in a community and a hospital respectively. Those who were Leishmania donovani positive, Giardia lamblia positive or Strongyloides stercoralis positive more easily suffered from PTB than those who were negative and RR values (95% CI) were 1.73 (1.14-2.62), 1.80 (1.10-2.93) and 3.11 (1.53-6.35), respectively. Likewise, persons with PTB were more easily infected by Leishmania donovani, Giardia lamblia or Strongyloides stercoralis than persons without PTB and RR values (95% CI) were 1.24 (1.08-1.43), 1.86 (1.09-3.16) and 4.26 (1.42-12.77), respectively.
      Table 4

      The interrelationship of infection between TB and parasitic diseases

      Country

      Year of report

      Parasitic disease

       

      PTB (+)

      PTB (−)

      RRrow(95% CI)

      P-value

      No. of reference

      Sudan

      2004

      Leishmania donovani

      +

      77

      175

      1.73 (1.14-2.62)

       

      [31]

         

      _

      23

      107

      1.00

        
        

      RR col (95% CI)

       

      1.24 (1.08-1.43)

      1.00

       

      0.0067

       

      Ethiopia

      2006

      Intestinal parasites

      +

      32

      202

      1.10 (0.74-1.63)

       

      [32]

         

      _

      68

      480

      1.00

        
        

      RR col (95% CI)

       

      1.08 (0.79-1.47)

      1.00

       

      0.6272

       
        

      Helminths

      +

      16

      139

      0.77 (0.46-1.28)

        
         

      _

      84

      543

      1.00

        
        

      RR col (95% CI)

       

      0.78 (0.49-1.26)

      1.00

       

      0.3047

       
        

      Ascaris lumbricoides

      +

      5

      83

      0.42 (0.17-0.99)

        
         

      _

      95

      599

      1.00

        
        

      RR col (95% CI)

       

      0.41 (0.17-0.99)

      1.00

       

      0.0341

       
        

      Giardia lamblia

      +

      15

      55

      1.80 (1.10-2.93)

        
         

      _

      85

      627

      1.00

        
        

      RR col (95% CI)

       

      1.86 (1.09-3.16)

      1.00

       

      0.0233

       
        

      Entamoeba histolytica

      +

      10

      40

      1.63 (0.90-2.93)

        
         

      _

      90

      642

      1.00

        
        

      RR col (95% CI)

       

      1.70 (0.88-3.30)

      1.00

       

      0.1145

       
        

      Hookworm

      +

      6

      30

      1.32 (0.62-2.81)

        
         

      _

      94

      652

      1.00

        
        

      RR col (95% CI)

       

      1.36 (0.58-3.19)

      1.00

       

      0.4451*

       
        

      Taenia species

      +

      2

      23

      0.62 (0.16-2.36)

        
         

      _

      98

      659

      1.00

        
        

      RR col (95% CI)

       

      0.59 (0.14-2.48)

      1.00

       

      0.7594*

       
        

      Strongyloides stercoralis

      +

      5

      8

      3.11 (1.53-6.35)

        
         

      _

      95

      674

      1.00

        
        

      RR col (95% CI)

       

      4.26 (1.42-12.77)

      1.00

       

      0.0172*

       
        

      Trichuris trichiura

      +

      1

      7

      0.98 (0.15-6.17)

        
         

      _

      99

      675

      1.00

        
        

      RR col (95% CI)

       

      0.97 (0.12-7.84)

      1.00

       

      1.0000*

       

      +: infected; -: noninfected; *: Fisher’s exact test; Abbreviation: PTB = pulmonary tuberculosis; RR = risk ratio; CI = confidence interval.

      Immunological research of co-infection between TB and parasitic diseases during 1989 to 2012 are shown in Table 5. In four studies that reported a change of activity of the host’s immune system when the course of TB was aggravated by opisthorchiasis invasion, the activity increased at the acute stage of invasion and decreased at the subacute stage or in the chronization. A study from France showed that co-infecton of American cutaneous leishmaniasis, lepromatous leprosy and PTB downregulated the T-helper (Th) 1 cell response. Four studies on co-infection with Mycobacterium tuberculosis (M. TB) and malaria showed that malarial parasites decreased the host’s effective humoral and cellular immune responses to M. TB, and co-infection exacerbated chronic TB, suggesting a competitive antagonist effect between heat shock protein 70 (HSP70) from M. TB and adenosine triphosphate-binding protein (ATPBP) of malaria may exist. Two studies suggested that the impact of co-infection between filarial infection and M. TB infection on the immune response was uncertain. Four studies reported immunomodulation characteristics of co-infection beween TB and intestinal helminths. A study from China indicated that as the echinococcosis chronicity increased, the immune profile in TB patients changed from a Th1 to Th2 response. In three other studies in which the effect of infection of intestinal parasites and Schistosoma mansoni on the protective immune response to Bacillus Calmette-Guerin (BCG) vaccination against M. TB and the effect of malaria infection on the effectiveness of novel TB vaccines in protecting against TB were evaluated, the protective efficacy of BCG vaccination was reduced but the effectiveness of novel TB vaccines was unaffected.
      Table 5

      Immunological research of co-infection between TB and parasitic diseases

      Country

      Year of report

      Tuberculosis

      Parasitic disease/species

      Subject

      Conclusions

      No. of reference

      France

      2003

      PTB

      American cutaneous leishmaniasis

      A 44-year-old man with triple infection of cutaneous leishmaniasis, lepromatous leprosy, and PTB

      Unresponsiveness to IL-12 of patient’s T cells after stimulation with Leishmania guyanensis, M. bovis bacille Calmette-Guerin, and M. leprae antigens suggested the inability to mount an appropriate Th cell response to upregulate the IL-12 receptor expression.

      [14]

      Gambia

      1999

      M. TB

      Malaria

      Review

      Malarial parasites can decrease their vertebrate host’s effective humoral and cellular immune responses to M. TB.

      [35]

      USA

      2004

      M. TB

      Plasmodium yoelii NL

      Mice

      Co-infected mice were less able to contain growth of M. TB in lung, spleen, and liver and had increased mortality.

      [36]

      Thailand

      2006

      M. TB

      Plasmodium falciparum

      HSP70 (M. TB) and ATPBP (Plasmodium falciparum)

      HSP70 and ATPBP share a common molecular function as ATP binding resulting from purine nucleotide binding. Therefore, a competitive antagonist effect between both molecules can be expected.

      [37]

      Germany

      2012

      M. TB

      Plasmodium berghei NK65

      An experimental mouse model of co-infection

      Co-infection exacerbated chronic TB while rendering mice less refractory to Plasmodium. Co-infected animals presented with enhanced inflammatory immune responses as reflected by exacerbated leukocyte infiltrates, tissue pathology and hypercytokinemia accompanied by altered T-cell responses.

      [38]

      Unknown

      1989

      PTB

      Opisthorchiasis

      173 patients with PTB complicated by opisthorchiasis

      Among them, activity of the α1-proteinase inhibitor was more frequently higher and carriers of two markers i.e. Hp 2–2 and Gc 1–1 were more frequent.

      [39]

      Unknown

      1992

      PTB

      Opisthorchiasis

      12 PTB patients concurrent with opisthorchiasis

      When the course of TB is aggravated by opisthorchiasis invasion, the number of cases of antibacterial therapy intolerance increases and prognosis of the diseases deteriorates. It was shown that the antibacterial and anthelminthic therapy had a favourable clinical and immunologic effect.

      [40]

      Unknown

      1992

      M. TB

      Opisthorchiasis

      Animal

      In comparison with the groups of animals with monoinvasion and monoinfection, at the acute invasive phase of mixed pathology (2 weeks) the activity of the host’s immune system increases, while the biological activities of both pathogens decrease; however, at the subacute phase (2.5 months), all were contrary respectively.

      [41]

      Russia

      2003

      TB

      Opisthorchiasis

      Golden hamsters with SRBC parasitocenosis

      In cases of mixed pathology, at the acute stage of invasion, the immune system showed increased responses with respect to specific and heterologous antigens; in the chronization of invasion the formation of antibodies to heterologous antigens (SRBC) and the level of specific antiopisthorchiasis and anti-TB immune responses decreased together.

      [42]

      China

      2009

      PTB

      Echinococcosis

      A 18 years old male and a 36 years female

      As the echinococcosis chronicity increased, the immune profile in both subjects changed from a Th1 to Th2 response. Such an elevated Th2 immune profile, with subsequent suppression of the Th1 immune response, is a common feature of chronic helminth infections.

      [27]

      USA

      2012

      M. TB

      Litomosoides sigmodontis

      Cotton rats with chronic L. sigmodontis infection and uninfected controls were challenged with M. TB by intranasal inoculation.

      Chronic filarial infections do not exacerbate M. TB infection in the cotton rat model. It may be possible to develop worm-derived therapies for autoimmune diseases that do not substantially increase the risk for infections.

      [43]

      USA

      2012

      M. TB

      Filarial infections

      Review

      Filarial infections very clearly alter the magnitude and quality of the mycobacteria-specific cytokine responses, responses that have been typically associated with control of these intracellular pathogens.

      [44]

      Denmark

      2007

      TB

      Intestinal helminth

      Review

      Co-infections cause a range of immunomodulation characterized by enhanced Th2-type cytokine profiles, high IgE levels and upregulated regulatory T-cell activity, as well as chronic immune activation.

      [45]

      Brazil

      2007

      PTB

      Intestinal helminth

      40 PTB patients and 25 healthy controls

      Compared to either TB patients or healthy controls, co-infected patients’ absolute frequencies of CD3+, CD4+, CD8+, NK T cell and CD4+CD25high T cell increased. Differences in CD4 T cell frequencies were accompanied by lower IFN-γ and elevated and sustained IL-10 levels in WB cultures from co-infected patients compared to TB patients.

      [46]

      Mexico

      2012

      TB

      Helminthic infections

      Review

      Helminths very clearly alter the magnitude of the mycobacteria-specific cytokine responses, altering the control of the mycobacteria growth. Mycobacteria-induced immune responses are suppressed by helminth infections.

      [47]

      USA

      2012

      TB

      Helminths

      Review

      Helminth-induced Th2 and T reg responses impinge on host resistance against M. TB infection. Th1 response is reduced in helminth co-infected hosts. Helminth-induced alternatively activated macrophages contribute to enhanced susceptibility to TB.

      [48]

      Brazil

      2002

      BCG vaccination

      Ascaris lumbricoides, Entamoeba histolytica, and Strongyloides stercoralis

      14 male students aged 12–15 years: 7 having protozoan or helminthic infections and 7 free of intestinal parasites

      Th2-like IL-10 responses induced by intestinal parasites may interfere in BCG-induced Th1-like IFN-γ response. Intestinal parasitic infections may significantly alter the protective immune response to BCG vaccination.

      [49]

      Sweden

      2005

      BCG vaccination to protect against M. TB

      S. mansoni

      BCG vaccinated mice with prior S. mansoni infection

      S. mansoni infection reduces the protective efficacy of BCG vaccination against M. TB possibly by attenuation of protective immune responses to mycobacterial antigens and/or by polarizing the general immune responses to the Th2 profile.

      [50]

      USA

      2011

      TB vaccines in protecting against M. TB

      Plasmodium yoelii NL

      TB vaccines in a co-infection mouse model of two pathogens

      The effectiveness of novel TB vaccines in protecting against TB was unaffected by a primary malaria co-infection in a mouse model of PTB.

      [51]

      Abbreviations: PTB = pulmonary tuberculosis; M. leprae = mycobacterium leprae; M. TB = mycobacterium tuberculosis; SRBC = sheep red blood cells; IL = interleukin; Th = T helper; Treg = T regulatory; NL = non-lethal; HSP = heat shock protein; ATP = adenosine triphosphate; ATPBP = ATP-binding protein; Ig = immunoglobulin; CD = cluster of differentiation; NK = natural killer; IFN = interferon; WB = whole blood; BCG = Bacillus Calmette-Guerin; L. sigmodontis = litomosoides sigmodontis; S. mansoni = schistosoma mansoni.

      Discussion

      This review only found 24 cases of co-infection with TB and parasitic diseases but they distributed widely in 13 countries and covered PTB, extrapulmonary TB, and diseases caused by protozoa and helminths [829]. We also found 5 epidemiological studies in which prevalence of co-infection varied widely [3034], and found that it was evident in 18 studies that the activity of the host’s immune system was altered during co-infection happened [27, 3442, 4451]. Therefore, assessing co-infection characteristics, influencing factors and impact on immunity is important to control and prevention whether for TB or parasitic diseases.

      About 17 parasite genera concurrent with M. TB were reviewed as case reports, epidemiological surveys and immunological research, which were divided into protozoa (Entamoeba[32, 49], Leishmania[816, 31], Giardia lamblia[28, 32], Trichomonas[17], Plasmodium[18, 33, 35, 37, 38], Toxoplasma[1921]) and helminths (Clonorchis sinensis[30], Opisthorchis[39, 40], Schistosoma[22, 33, 34], Taenia[32], Echinococcus[2327], Ascaris lumbricoides[32, 34, 49], Toxocara[20], Trichuris trichiura[30, 32, 34], Ancylostoma[3234], Strongyloides stercoralis[28, 32, 34, 49], Filaria[29, 43, 44]) and covered most of the common parasites species. Of those, leishmaniasis, hydatid disease and malaria were reported to coexist more freuequently with TB in the human body. In addition to co-infection of TB and a single parasitic disease, there was also co-infection of TB and multiple parasitic diseases, such as co-infection of pneumocystis carinii pneumonia, visceral leishmaniasis and PTB, co-infection of toxoplasmosis, toxocariasis and TB, and co-infection of strongyloidiasis, giardiasis and TB [9, 20, 28].

      Possibly gender differences exist in co-infection of TB and different parasitic diseases. Among ten cases reported to be co-infected with TB and leishmaniasis, only two cases were female [816], however, only one of six cases co-infected with TB and hydatid disease was male [2327]. In spite of these limited data without epidemiological evidence, we can infer that different social roles associated by gender possibly result in different probabilities of contacting different parasites resulting in different incidence and prevalence. An epidemiological survey in subtropical Ecuador suggested that male gender was one of risk factors associated with cutaneous leishmaniasis [53]. Contrarily, a population-based study in the Hamar of Ethiopia indicated that hydatid disease was a public health problem for women [54]. Irrefutably, gender differentials also exist in the prevalence of TB [55].

      Although no significant age clustering was found in 23 cases of co-infecion who had a huge age span ranging from 34 days old to 82 years old [829], however, there were fewer reported cases of less than 20 years old and more than 60 years old. Likewise, this limited data were not epidemiological results. Nevertheless, age differentials of co-infection also exist and should not be a neglected factor. A cross-sectional household survey in Sudan showed that percentages of leishmania skin tests and tuberculin positivity by age group increased [31], which possibly reflects that with the increasing age, not only does the immune response increase following exposure to infection but also opportunities of exposure to infection increase gradually.

      Among TB patients, prevalence of parasitic disease varies widely in different areas and different survey sites. TB and parasitic disease co-infection is common in clinical practice in East Africa. In Sudan, up to 77% of TB patients were positive for the leishmania skin test in the community [31]; 32% of TB patients from hospitals had intestinal parasites and 29% of TB patients from the community had intestinal helminths in Ethiopia [32, 34]; and 32.4-38.2% of TB patients from hospitals were also infected with Schistosomes in Tanzania [33]. We also noticed the prevalence differentials in Korea, where the infection rates of Trichocephalus trichiurus and Clonorchis sinensis were 20.7% and 17.6% respectively among TB patients in one hospital, but the infection rates were 6.5% and 6.0% respectively in another hospital [30]. Among the PTB patients from a hospital in Tanzania, the HIV-positive patients had a significantly lower prevalence of hookworm and Schistosome infection and a higher prevalence of malaria than the HIV-negative patients [33], which indicates HIV also has an impact on prevalence of co-infection.

      Therefore, it is no surprise to find many factors that possibly affect co-infection of TB and parasitic diseases. First, socio-demographics, such as gender and age as previously mentioned above, maybe relate to prevalence of co-infection. Second, some special patients, such as renal transplant recipients, patients on maintenance haemodialysis, HIV positive patients and migrants [8, 1012, 14, 16, 21, 22, 28, 33], are likely to be susceptible populations of co-infection. Last but not least, there are higher probabilities of co-infection in some areas with a higher prevalence of TB and parasitic diseases, such as India and East Africa [11, 12, 16, 18, 23, 29, 3134]. These might provide useful information to control and prevent co-infection of TB and parasites under the background of very few epidemiological surveys for co-infection to date.

      It was observed that PTB and parasitic diseases were risk factors for each other. We analyzed the data of an epidemiological survey in Sudan and found that Leishmaniasis patients had a 1.73 times higher risk for PTB than individuals without Leishmania and PTB patients had a 1.24 times higher risk for Leishmaniasis than individuals without PTB [31]. We also found data from an epidemiological survey in Ethiopia that Giardiasis and Strongyloidiasis patients all had higher risks for PTB than persons without Giardia lamblia and Strongyloides stercoralis, respectively, and PTB patients had a higher risk for Giardiasis and Strongyloidiasis than persons without PTB [32].

      In comparison with mono-infection, co-infection makes the host’s immune system have to deal with a more complex internal environment. The usual manifestation is that clinical signs might become more frequent and serious and therapy may be affected when TB patients are also infected by parasites. Both clinical and laboratory based studies showed that when the course of TB was aggravated by opisthorchiasis invasion, clinical signs of TB became more pronounced, disorders in the functions of the liver and pancreas became more frequent, antibacterial therapy intolerance increased and prognosis of the disease deteriorated [39, 40]. In order to clarify these situations, some studies were conducted to evaluate the immuno-pathogenesis of co-infection. Limited data from two studies showed that the immune response of TB patients increased at the acute stage of opisthorchiasis invasion and decreased at the subacute stage or in the chronization [41, 42]. Two studies indicated that malarial parasites decreased the hosts effective humoral and cellular immune responses to M. TB [35, 36], and another study using an experimantal animal model showed co-infection between TB and malaria exacerbated chronic TB while rendering mice less refractory to Plasmodium[38]. Another study found that with the increase of echinococcosis chronicity, the immune profile in TB patients displayed an elevated Th2 immune reponse with subsequent suppression of the Th1 immune response [27]. Although one study suggested chronic filarial infections do not exacerbate M. TB infection [43], a review pointed out that filarial infections very clearly alter the magnitude and quality of the mycobacteria-specific cytokine response [44]. Generally, it is observed that the host’s immune system is inhibitited to a great extent during co-infection.

      Some investigations observed the change of levels of immune indexes during co-infection. A study on co-infection of PTB and opisthorchiasis found that among co-infected patients, activity of the α1-proteinase inhibitor was more frequently higher and carriers of two markers i.e. Hp 2–2 and Gc 1–1 were more frequent [39]. A study on triple infection of leishmaniasis, TB and leprosy showed that patients were unable to mount a Th cell response to upregulate the interleukin-12 receptor expression after stimulation of the triple infection [14]. The investigation of co-infection between TB and intestinal helminths suggested that compared to either TB patients or healthy controls, the absolute frequencies of CD3+, CD4+, CD8+, Natural killer T cell and CD4+CD25high T cell increased in co-infected patients [46]. Indeed, the change of immune index levels reflects a ‘weakened’ immune response.

      It is worthwhile evaluating the impact of parasitic disease infection on the efficacy of BCG vaccination against M. TB. Ferreira et al.[49] and Elias et al.[50] found that intestinal parasitic infections might significantly alter the protective immune response to BCG vaccination and/or polarize the general immune response to the Th2 profile since Th2-like interleukin-10 responses induced by intestinal parasites might interfere in the BCG-induced Th1-like interferon-γ response. Therefore, in areas of high prevalence of co-infection, anti-parasitic chemotherapy prior to immunization may greatly enhance the efficacy of BCG vaccination.

      Conclusion

      This review has found limited evidence of factors that influence epidemic and host’s immunity of co-infection between TB and parasitic disease in humans. Most of the common parasites species are concurrent with M. TB in multiple organs, which increase antibacterial therapy intolerance and deteriorate prognosis of disease. Socio-demographics such as gender and age, special populations with susceptibility, such as renal transplant recipients, patient on maintenance haemodialysis, HIV positive patients and migrants, and living in or coming from co-endemic areas likely have impacts on co-infection. PTB and parasitic diseases were shown to be risk factors for each other. Co-infection may inhibit the hosts immune system to a great extent. In addition, infection with parasites can alter the protective immune response to BCG vaccination against M. TB.

      Declarations

      Acknowledgement

      This work is supported in part by National S & T Major Program (grant no. 2012ZX10004-220).

      Authors’ Affiliations

      (1)
      National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, Key Laboratory of Parasite and Vector Biology, Ministry of Health, WHO Collaborating Centre for Malaria, Schistosomiasis and Filariasis
      (2)
      National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention

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      This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://​creativecommons.​org/​licenses/​by/​2.​0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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