Thesis (MScMedSc)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: Individuals latently infected with Mycobacterium tuberculosis (M.tb) contain the infection without showing signs of illness. Steroid hormones such as glucocorticoids (GCs) however can lead to reactivation of TB. Currently two different injectable contraceptives are available in South Africa, medroxyprogesterone acetate (MPA) and norethisterone enanthate (NET). MPA is able to bind to and activate the glucocorticoid receptor (GR) and possesses selective GC activity, a pharmacological characteristic absent in NET. The aim of this study was to investigate the immune modulatory effects of the two contraceptives MPA and NET on immune responses to mycobacteria in vitro and in vivo. Human peripheral blood mononuclear cells (PBMCs) were infected with BCG (M. bovis Bacille Calmette-Guérin) and treated with MPA, NET, progesterone or cortisol and cytokine expression was measured in order to determine whether the synthetic progestins mimic endogenous progesterone or the GC cortisol. MPA, but not NET suppressed the expression of IFN-γ, IL-1α, IL-1β, IL-2, IL-12p40 and IL-13 similarly to cortisol. Furthermore expression of miRNAs, small double stranded RNA molecules that bind to complementary sequences in mRNAs of target genes and cause their degradation, was determined under the different experimental conditions. The expression of several miRNAs including miR-30c, miR-222, miR-454 and miR-331-3p were differentially influenced by MPA, cortisol and/or NET in PBMCs stimulated with BCG. For example, BCG induced the expression of miR-454 (p=0.003) which was then inhibited to basal levels by cortisol (p=0.008), MPA (p=0.002) and NET (p=0.002). These results demonstrate that steroid hormones including the contraceptives MPA and NET can modulate immune responses to mycobacteria at the miRNA level. To determine the effect of MPA and NET on BCG-induced expression of miRNAs in vivo a mouse model was used. C57BL/6 mice were injected weekly with either MPA or NET using a dose equivalent to humans and then infected with BCG. Mice treated with MPA had a higher spleen bacterial load 21 days after infection compared to both NET treated and control mice (p=0.023). In whole blood, MPA and NET treatment suppressed the BCG-induced production of miR-100 and miR-509-3p to basal levels. In contrast to NET, MPA induced expression of miR-99a expression independent of BCG infection. In the lung, the site of disease, a total number of 22 out of 377 miRNAs tested were differentially expressed 21 days after infection. The results of this study indicate that both synthetic progestins altered the immune response to BCG at the level of cytokine expression as well as the miRNA level. MPA was found to mimic cortisol by inhibiting secretion of inflammatory cytokines whereas NET appeared to have more progestogenic properties. Each of the steroid hormones was observed to induce a characteristic miRNA expression profile, both in vitro as well as in vivo, although not identical. These results highlight that the two contraceptives – although used interchangeably by women in developing countries - are pharmacologically unique and differentially modulate immune responses to mycobacteria. These data support the urgent need for further research into the link between hormonal contraceptives and susceptibility to infectious diseases. / AFRIKAANSE OPSOMMING: Individue wat latent met Mycobacterium tuberculosis ( M.tb ) geïnfekteer is, onderdruk die infeksie en wys geen simptome van die siekte nie. Steroïed hormone soos glukokortikoïede (GKe) kan egter tot die heraktivering van TB lei. Daar is tans twee verskillende inspuitbare voorbehoedmiddels beskikbaar in Suid-Afrika, medroksiprogesteroon-asetaat (MPA) en noretisteroon enantaat (NET). MPA is staat om aan die glukokortikoïed reseptor (GR) te bind en dit te aktiveer. MPA beskik ook selektiewe GK aktiwiteit, 'n farmakologiese eienskap wat afwesig is in NET. Die doel van hierdie studie was om die immuun-regulerende effekte van die twee voorbehoedmiddels, MPA en NET, op immuunresponse teen mikobakterieë in vitro en in vivo te ondersoek. Menslike perifêre bloed mononukleêre selle (PBMSe) is met BCG geïnfekteer en met MPA, NET, progesteroon of kortisol behandel. Sitokien uitdrukking was gemeet om vas te stel of die sintetiese progestiene, endogene progesteroon of die GK kortisol naboots. MPA, maar nie NET, onderdruk die produksie van IFN-γ, IL- 1α, IL- 1β, IL- 2, IL- 12p40 en IL- 13 soortgelyk aan kortisol. Verder is uitdrukking van miRNAs, klein dubbelstring RNS molekules wat aan komplimentêre volgorde in mRNAs van teiken gene bind en wat hul degradering veroorsaak, bepaal in elk van die verskillende eksperimentele toestande. Die uitdrukking van verskeie miRNAs insluitende miR-30c, miR-222, miR-454 en miR-331-3p is differensieël beïnvloed deur MPA, kortisol en/of NET in PBMSe wat met BCG gestimuleer is. Byvoorbeeld, BCG veroorsaak die uitdrukking van miR-454 wat dan geïnhibeer word tot agtergrondvlakke deur kortisol, MPA en NET. Hierdie resultate toon dat steroïed hormone, insluitend die voorbehoedmiddels MPA en NET, die immuunrespons teen mikobakterieë op miRNA-vlak affekteer. Om die effek van MPA en NET op BCG-geïnduseerde uitdrukking van miRNAs in vivo te bepaal, is ʼn muismodel gebruik. C57BL/6 muise is weekliks met 'n dosis van MPA of NET, ekwivalent aan dosisse gebruik in die mens, ingespuit en met BCG geïnfekteer. Muise wat met MPA behandel is, het 'n hoër bakteriële lading in die milt 21 dae na infeksie in vergelyking met NET-behandelde muise en kontrole muise. In hul bloed, onderdruk MPA en NET behandeling die BCG-geïnduseerde produksie van miR-100 en miR-509-3p tot basale vlakke. In teenstelling met NET, induseer MPA die uitdrukking van miR-99a onafhanklik van BCG infeksie. In die long is 'n totaal van 23 miRNAs differensieël uitgedruk 21 dae na die infeksie. Die resultate van hierdie studie dui daarop dat beide sintetiese progestien die immuunrespons teen BCG verander op sitokien sowel as miRNA vlak. MPA boots hoofsaaklik kortisol na deur inhibering van sitokien-produksie terwyl NET meer progesterone eienskappe het. Op miRNA vlak veroorsaak elk van die steroïed hormone 'n kenmerkende miRNA uitdrukkingsprofiel, beide in vitro asook in vivo. Hierdie resultate beklemtoon dat die twee voorbehoedmiddels - alhoewel hulle afwisselend gebruik word deur vroue in ontwikkelende lande - farmakologies uniek is en differensieël die immuunrespons reguleer teen Mycobacterium. Hierdie data ondersteun die dringende behoefte aan verdere navorsing in verband met hormonale voorbehoedmiddels en vatbaarheid vir aansteeklike siektes.

Thesis (MScMedSc)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: Central dogma suggests that mutations in target genes is the primary cause of resistance to first and second-line anti-TB drugs in Mycobacterium tuberculosis. However, it was previously reported that approximately 5% of Rifampicin mono-resistant clinical M. tuberculosis did not harbor mutations in the rpoB gene. The present study hypothesized that active efflux plays a contributory role in the level of intrinsic resistance to different anti-TB drugs (Isoniazid, Ethionamide, Pyrazinamide, Ethambutol, Ofloxacin, Moxifloxacin, Ciprofloxacin, Streptomycin, Amikacin and Capreomycin in RIF mono-resistant clinical M. tuberculosis isolates with a rpoB531 (Ser-Leu) mutation. This study aimed to define the role of Efflux pump inhibitors (verapamil, carbonylcyanide m-chlorophenylhydrazone and reserpine) in enhancing the susceptibility to different anti-TB drugs in the RIF mono-resistant clinical isolates. The isolates were characterized by determining the level of intrinsic resistance to structurally related/unrelated anti-TB drugs; determining the effect of EPIs on the level of intrinsic resistance in the isolates and comparing the synergistic properties of the combination of EPIs and anti-TB drugs. To achieve this, genetic characterization was done by PCR and DNA sequencing. Phenotyping was done by the MGIT 960 system EpiCenter software to determine the MICs of the different anti-TB drugs and the effect of verapamil and carbonylcyanide m-chlorophenylhydrazone on determined MICs. Due to inability to test reserpine in a MGIT, a different technique (broth microdilution) was used for the reserpine experiment. Additionally; fractional inhibitory concentrations (FIC) indices were calculated for each of these drugs. The FIC assess the anti-TB drugs/inhibitor interactions. STATISTICA Software: version 11 was used for statistical analysis. Results revealed that the RIF mono-resistant isolates were sensitive at the critical concentrations of all 10 drugs tested, with the exception of Pyrazinamide. This could be explained by the technical challenges of phenotypic Pyrazinamide testing. A significant growth inhibitory effect was observed between the combination of EPI and anti-TB drug exposure in vitro. This suggests that verapamil, carbonylcyanide m-chlorophenylhydrazone and reserpine play a significant role in restoring the susceptibility (decrease in intrinsic resistance level) of the RIF mono-resistant isolates to all anti-TB drugs under investigation. Additionally, a synergistic effect was observed by the combination treatment of the anti-TB drugs with the different EPIs. Based on these findings, we proposed a model suggesting that efflux pumps are activated by the presence of anti-TB drugs. The activated pumps extrude multiple or specific anti-TB drugs out of the cell, this in turn decrease the intracellular drug concentration, thereby causing resistance to various anti-TB drugs. In contrast, the addition of EPIs inhibits efflux pump activity, leading to an increase in the intracellular drug concentration and ultimate cell death. This is the first study to investigate the effect of different efflux pumps inhibitors on the level of intrinsic resistance to a broad spectrum of anti-TB drugs in drug resistant M. tuberculosis clinical isolates from different genetic backgrounds. The findings are of clinical significance as the combination of treatment with EPI and anti-TB drugs or use of EPIs as adjunctives could improve MDR-TB therapy outcome. / AFRIKAANSE OPSOMMING: Sentrale dogma beweer dat mutasies in teiken gene die primêre oorsaak van die weerstandheid teen anti-TB-middels in Mycobacterium tuberculosis is. Vorige studies het getoon dat ongeveer 5% van Rifampisien enkelweerstandige kliniese M. tuberculosis isolate nie ‘n mutasie in die rpoB geen het nie. Die hipotese van die huidige studie was dat aktiewe pompe 'n bydraende rol speel in die vlak van intrinsieke weerstandheid teen 10 verskillende anti-TB-middels (Isoniasied, Ethionamied, Pyrazinamied, Ethambutol, Ofloxacin, Moxifloxacin, Siprofloksasien, Streptomisien, Amikasien and Capreomycin) in RIF enkelweerstandige kliniese M . tuberculosis isolate met 'n rpoB531 (Ser-Leu) mutasie. Die doel van hierdie studie was om die rol van uitpomp inhibeerders (verapamil, carbonylcyanide m-chlorophenylhydrazone en reserpien) te definieer in die verbetering van die werking vir verskillende anti-TB-middels in die RIF enkelweerstandige kliniese isolate. Die doelstellings van die studie was om die vlak van intrinsieke weerstandigheid teen struktureel verwante/onverwante anti-tuberkulose middels asook die effek van die EPIs op die vlak van intrinsieke weerstand in die isolate is bepaal. Verder is sinergistiese eienskappe van die kombinasie van EPIs en anti-TB-middels ondersoek. Hierdie doelstellings is bereik deur genetiese karakterisering deur PKR en DNS volgorde bepaling. Fenotipering is gedoen deur gebruik te maak van MGIT 960 EpiCenter sagteware om die Minimum Inhibisie Konsentrasie (MIC) van die verskillende anti-TB-middels en die effek van verapamil en carbonylcyanide m-chlorophenylhydrazone op die MIC te bepaal. Reserpien kan nie in die MGIT sisteem getoets word nie, and daarom is 'n ander tegniek (mikro-verdunning) is gebruik om die effek van reserpien te toets. Fraksionele inhiberende konsentrasies (FIC) is bereken vir elk van hierdie middels die anti-TB-middels / inhibeerder interaksies te bepaal. STATISTICA v11 sagteware is gebruik vir alle statistiese analises. Resultate van hierdie studie toon dat die RIF enkelweerstandige isolate sensitief is teen kritieke konsentrasies van al die middels, met die uitsondering van Pyrazinamied. Weerstandigheid van Pyrazinamied kan wees as gevolg van welbekende tegniese probleme met die standaard fenotipiese pyrazinamied toets. ‘n Beduidende groei inhiberende effek is waargeneem tussen die kombinasie van EPI en anti-TB middel blootstelling in vitro. Dit dui daarop dat verapamil, CCCP en reserpine 'n belangrike rol speel in die herstel van die sensitiwiteit (afname in intrinsieke weerstand vlak) van die RIF enkelweerstandige isolate aan alle anti-TB-middels wat ondersoek is. Daarbenewens is 'n sinergistiese effek waargeneem deur die kombinasie van die verskillende anti-TB-middels en die verskillende EPIs. Op grond van hierdie bevindinge het ons ‘n model voorgestel wat toon dat uitvloei pompe geaktiveer word deur die teenwoordigheid van anti-TB-middels en die geaktiveerde pompe dan verskeie of spesifieke anti-TB-middels uit die sel pomp. Dus verminder die intrasellulêre konsentrasie van die middel en veroorsaak daardeur weerstandigheid teen verskeie anti-TB-middels. Die byvoeging van EPIs inhibeer uitvloei pompe se werking en lei tot 'n toename in die intrasellulêre konsentrasie van die middels en uiteindelik die dood van die selle. Hierdie is die eerste studie wat die effek van verskillende uitvloei pompe inhibeerders op die vlak van intrinsieke weerstand teen 'n breë spektrum van anti-TB-middels in die middel-weerstandige kliniese isolate ondersoek. Die bevindinge kan van belangrike kliniese belang wees aangesien die kombinasie van behandeling met EPI en anti-TB-middels die uitkoms MDR-TB terapie kan verbeter.

Thesis (PhD)--Stellenbosch University, 2012. / ENGLISH ABSTRACT: Tuberculosis (TB) is a major cause of morbidity and mortality across the world, affecting adults and children. Children infected with TB differ from adults, as their immunological and patho-physiological response to the disease is different. Although there are a variety of tests available for TB diagnosis, they have limitations when used to diagnose paediatric TB. Children are also unable to generate sputum spontaneously when required for the use in culture or microscopy as diagnostic method. Children however do produce sputum, containing the TB bacilli, which they swallow. If the TB bacilli can therefore be retrieved from the stomach and tested, TB can be diagnosed using gastric samples. In this thesis, a variety of styrene maleimide copolymer (SMI) derivatives were prepared as potential M. tuberculosis-capturing platforms. This was done by modifying poly(styrene-co-maleic anhydride) (SMA) with a variety of primary amine compounds, selected based on possible chemical interactions with the M. tuberculosis cell wall. All the prepared copolymer derivatives were electrospun into nanofibrous mats using the single needle electrospinning technique to yield SMI nanofibers, functionalized with different compounds. Some of the functionalized SMI nanofibers were prepared by surface-functionalization of the polymer nanofibers after electrospinning and some by modification of the polymer before electrospinning. Affinity studies were conducted at neutral and low pH between the different functionalized SMI nanofibers and two mycobacterium strains, namely the bacillus Calmette-Guérin strain of Mycobacterium bovis (BCG) and M. tuberculosis, to evaluate the surfaces of the modified SMI nanofibers as mycobacterium-capturing platforms. The successful capture of BCG onto the surfaces of the various functionalized nanofibers was confirmed by SEM and fluorescence microscopy (FM). Analysis of the SEM and FM images indicated that the SMI nanofibers, functionalized with a C12 aliphatic quaternary ammonium moiety (SMI-qC12), captured BCG the most effectively through a combination of ionic and hydrophobic interaction. Concentration and time studies revealed that the extent of this interaction was dependent on incubation time and concentration of BCG. The affinity studies with BCG also concluded that the polymer used for the nanofibrous-capturing platform should not be too hydrophobic in character as this caused poor wetting of the functionalized nanofibers, thus preventing close contact with the mycobacteria and a reduction in the capture effectivity of the polymer nanofibers. The successful capture of M. tuberculosis onto the SMI-qC12 nanofibrous surface was confirmed by FM, light microscopy (LM) and polymerase chain reaction (PCR). The extent of this interaction was dependent on the concentration of M. tuberculosis. The detection of M. tuberculosis using FM and LM as detection methods was simplified by the tendency of M. tuberculosis to clump together in clusters on the hydrophobic surface of the SMI-qC12 nanofibers. As a result of this clustering, FM and LM were therefore regarded as feasible detection methods to image M. tuberculosis on the surface of the SMI-qC12 nanofibers, even at relatively low concentration of M. tuberculosis. / AFRIKAANSE OPSOMMING: Tuberkulose (TB) is 'n groot oorsaak van morbiditeit en mortaliteit regoor die wêreld en affekteer volwassenes en kinders. Kinders wat met TB geïnfekteer is, se immunologiese en patofisiologiese reaksie op die siekte verskil van die van volwassenes en dit het belangrike implikasies vir die diagnose van TB in kinders. Alhoewel daar 'n verskeidenheid van toetse beskikbaar is vir die diagnose van TB, het hulle beperkings wanneer dit gebruik word om pediatriese TB te diagnoseer. Kinders kan ook nie spontaan sputum produseer as dit nodig is vir die gebruik in kultuur of mikroskopie as diagnostiese metode. Kinders produseer egter wel sputum, wat die TB basille bevat, wat hulle dan insluk. As die TB basille uit die maag versamel kan word en getoets kan word, kan TB gediagnoseer word met behulp van maag monsters. In hierdie tesis is 'n verskeidenheid van stireen maleimied kopolimeer (SMI) afgeleides voorberei as potensiële Mycobacterium tuberkulose (Mtb)-vaslegging platforms. Dit is gedoen deur die modifikasie van poli(stireen-ko-maleïen anhidried) (SMA) met 'n verskeidenheid primêre amien verbindings as oppervlak-funksionaliseringsagente. Hierdie primêre amien verbindings is gekies op grond van moontlike chemiese interaksies met die Mtb selwand. Al die voorbereide kopolimeer afgeleides is elektrogespin in nanoveselagtige matte met behulp van die enkel-naald elektrospin tegniek om SMI nanovesels te lewer wat gefunksionaliseer is met verskillende verbindings. Sommige van die gefunksionaliseerde SMI nanovesels is berei deur oppervlak-funksionalisering van die polimeer nanovesels na elektrospin, en sommige deur die modifikasie van die polimeer voor elektrospin. Affiniteitstudies is uitgevoer, by neutrale en lae pH, tussen die verskillende gefunksionaliseerde SMI nanovesels en twee mikobakterium rasse, naamlik die basillus Calmette-Guérin ras van Mycobacterium bovis (BCG) en M. tuberculosis, om die oppervlaktes van die gewysigde SMI nanovesels te evalueer as mikobakterium-vaslegging platforms. Ontleding van die SEM en FM beelde het aangedui dat die SMI nanovesels, gefunksionaliseer met 'n C12 alifatiese kwaternêre ammonium groep (SMI-qC12), BCG die doeltreffendste vasgevang het deur 'n kombinasie van ioniese en hidrofobiese interaksie. Konsentrasie- en tydstudies tussen BCG en SMI-qC12 het aangedui dat die omvang van hierdie interaksie afhanklik is van inkubasietyd en konsentrasie van BCG. Die affiniteitstudies met BCG het ook aangedui dat die polimeer wat gebruik word vir die nanoveselagtige-vaslegging platform nie te hidrofobiese moet wees nie, aangesien dit swak benatting van die gefunksionaliseerde nanovesels veroorsaak, en dus noue kontak met die mikobakterieë voorkom met ʼn gevolglike vermindering in die vasvang-effektiwiteit van die polimeer nanovesels. Die suksesvolle vasvang van M. tuberculosis op die SMI-qC12 nanovesels is bevestig deur FM, lig mikroskopie (LM) en polimerase kettingreaksie (PKR). Die opsporing van Mtb deur die gebruik van FM en LM as opsporingmetodes is vergemaklik deur die tendens van Mtb om in groepies saam te pak op die hidrofobiese oppervlak van die SMI-qC12 nanovesels. As gevolg van hierdie groepering, is FM en LM dus haalbare opsporingmetodes om M. tuberculosis op die oppervlak van die SMI-qC12 nanovesels waar te neem, selfs by relatief lae konsentrasie van M. tuberculosis.

Thesis (DMed (Medicine. Internal Medicine))-University of Stellenbosch, 2005. / Mycobacterium tuberculosis (M. tuberculosis) accounts for more adult deaths than any other infectious agents. The present study included 162 patients with tuberculous pericarditis; 50% of the tuberculous pericarditis patients studied were human immunodeficiency virus (HIV) positive, compared to only 4.2% of patients who presented with non-tuberculous pericardial effusions. A steady year-to-year rise in HIV prevalence was observed in this 6-year study. Although the prognosis of pericardial tuberculosis (TB) is excellent with appropriate medical treatment, untreated pericardial TB has a mortality of 80-85%. It is thus important to diagnose tuberculous pericarditis efficiently. Traditionally, the diagnosis of pericardial TB is established by positive mycobacterial culture and/or histological evidence of necrotising granulomatous inflammation of the pericardium. Our study confirmed the insensitivity of pericardial fluid culture and pericardial biopsy in the diagnosis of pericardial TB, and at the time of clinical decision-making, results were usually not available. To overcome these difficulties, we explored various alternative strategies and this resulted in two diagnostic tools, namely a diagnostic rule and a diagnostic algorithm or classification tree. By means of classification and regression tree analysis, we allocated a weighted diagnostic index to each of five independently predictive features (fever, night sweats, weight loss, serum globulin >40 g/L and peripheral blood leukocyte count <10x109/L). A total diagnostic index of 6 or more corresponded to 82-86% sensitivity and 76-87% specificity for a diagnosis of tuberculous pericarditis. When possible, pericardial fluid should be aspirated to determine adenosine deaminase (ADA) levels and pericardial differential leukocyte counts. Fluid should also be sent for Gram stain and culture. The proposed diagnostic classification tree utilises the independently predictive attributes of pericardial adenosine deaminase levels, pericardial fluid lymphocyte/neutrophil ratios, peripheral leukocyte counts and the HIV status. Applying this prediction model to our entire data set of 233 patients resulted in 96% sensitivity and 97% specificity for the correct diagnosis of tuberculous pericarditis. Generally, patients were critically ill at the time of enrolment; 90% of tuberculous pericarditis presented with echocardiographic features of cardiac tamponade. Echoguided percutaneous pericardiocentesis with an indwelling catheter and intermittent daily aspiration was highly effective and safe. It is likely that the combination of this drainage technique and the early initiation of anti-tuberculous chemotherapy contributed to the almost complete absence of constriction in the patients studied, and our data do not support the routine use of adjunctive corticosteroids in patients with tuberculous pericarditis. Tuberculous exudates result from a Th1 mediated immune response characterised by lymphocyte dominance, significantly elevated levels of gamma-interferon (IFN-γ) and undetectable levels of interleukin-4 (IL-4). IFN-γ levels were not influenced by HIV status in spite of the severely diminished pericardial CD4+ lymphocyte counts observed in this study. It is thus likely that in HIV positive patients IFN-γ production is partly maintained by activated CD8+ T cells, which were significantly elevated in HIV positive patients compared to HIV negative tuberculous pericarditis patients. This finding underlines the importance of IFN-γ in the human immune response against M. tuberculosis. We also demonstrated that the presence of ADA in pericardial fluids reflects the activity of the cellular immune response. Both IFN-γ and ADA can be utilised as sensitive and specific diagnostic tools for pericardial TB.

Tuberculosis (TB) affects nearly a third of the world’s population and has been termed a ‘Global Emergency’ by the WHO. The emergence of multi/extensively drug resistant (M/XDR) strains of Mycobacterium tuberculosis (Mtb), the causative agent of TB, and the increasing incidences of azole drug resistant sterol demethylases (CYP51) from pathogenic fungi has propelled studies to understand mechanisms of azole drug resistance on the drug target CYP51. Since Mtb is devoid of a sterol biosynthetic pathway, the presence and study of CYP51B1 and 19 other Cytochrome P450s in its genome is important to clarify host-pathogen mechanism of infection and the potential of using azole drugs to treat TB. In this study, CYP51B1 from Mtb was used as the model enzyme to study CYP51 mutants from Candida albicans fluconazole-resistant clinical strains. By protein engineering methods, F89H, L100F, S348F, G388S and R391K CYP51B1 mutants were made and azole drug binding properties were investigated using stopped-flow kinetics and static equilibrium methods. Dissociation constant (Kd) values were derived for a range of commercially available azole drugs by fitting the equilibrium binding data to a hyperbolic equation. Kd values for stopped-flow kinetics were derived by plotting observed binding rates (kobs) across different azole drug concentrations against time, followed by fitting multiple kobs data to a linear equation to derive azole drug de-binding (koff) and binding (kon) rate constants – the Kd was obtained by koff/kon. Extinction coefficient for heme b content in mutants and Wild Type (WT) CYP51B1 were an average of ɛ419 = 96.1 mM-1 cm-1. Biochemical characterisation of the mutants were carried out using established experiments on CYP51 – reduction of Fe(III)-heme to Fe(II)-heme, NO binding to Fe(III)-heme, rates of CO-Fe(II) adduct formation and rates of collapse of the P450 to P420 species in the presence of CO and estriol with redox partners from Mtb. In order to elucidate the effects of the above mutations on the iron-heme catalytic region, electron paramagnetic resonance (EPR) experiments were carried out with and without azole drugs. Circular dichroism (CD), differential scanning calorimetry (DSC) and multi-angled laser light scattering (MALLS) analysis confirmed that F89H, R391K and L100F mutants were stable and homogeneous. Crystallogenesis was successful for the above mentioned mutants and atomic structures were obtained for all mutants and WT CYP51B1 (in ligand-bound and substrate-free forms), except for S348F and G388S mutants which were expressed as inclusion bodies and 60% holoenzyme, respectively. Reconstituted catalytic assays to determine the sterol demethylating propensity of the mutants were carried out using redox partners from Mtb or E. coli, and with lanosterol and dihydrolanosterol as the surrogate substrates. Redox potentiometry showed similar potentials to WT for all mutants except for the G388S mutant which was relatively positive (–102 mV). Redox cycling experiments followed by EPR analysis for mutants and WT resulted in a novel P450 high-spin species at g value 5.84 (80 %) which gradually collapsed to the initial low spin state over 48 h. Expression trials were concurrently carried out on two other Mtb P450 genes – CYP123 (Rv0744c) and CYP136 (Rv3059) products of which may have similar functions to CYP51B1 or may share similar redox partners. CYP123 is located on the same operon as CYP51B1 while CYP136 has a 29% sequence identity to another CYP51 from a marine slime bacterium. Although further work is necessary, in this study CYP123 was expressed totally as inclusion bodies while CYP136 was expressed as soluble apoprotein fused with trigger factor chaperone.

Thesis (MSc)--Stellenbosch University, 2016. / ENGLISH ABSTRACT: Tuberculosis (TB) is one of the world’s deadliest diseases, with one third of the population being infected by it. The diagnosis of active tuberculosis entails finding and identifying Mycobacterium tuberculosis (Mtb), the causative pathogen in a specimen of bodily fluid from the patient. Multiple samples will improve the diagnostic yield and specimen volumes should therefore be as large as possible, which is often challenging for patients and especially younger children. Alternatively, a smaller volume could be required if there was a manner in which to concentrate the bacteria within a specimen, through use of a substrate which has an affinity for the pathogenic species. Polymers having intrinsic cellular activity are of interest as such substrates, one such being the natural polysaccharide, chitosan. In this thesis, a variety of modified chitosan derivatives were prepared as potential Mtb-capturing substrates. This was achieved by modifying chitosan with a variety of moieties, selected based on possible interactions with the Mtb cell wall, to render various quaternary ammonium salts of the polymer chitosan. The quaternized chitosan derivatives were then used to synthesize nano-substrates having an affinity for Mtb. Polymer coated superparamagnetic magnetite nanoparticles (SPMNs) were synthesized via an in situ co-precipitation technique, in which modified chitosan is able to chelate with the metal core. Polymer nanofibers were also electrospun via the electrospinning technique. The prepared derivative, N-trimethylammonium chitosan chloride (TMC), was electrospun into nanofibers by blending with suitable non-ionogenic polymers, namely polyvinyl alcohol (PVA), polyethylene oxide (PEO), polyvinyl pyrrolidone (PVP) and polyacrylamide (PAM), required to facilitate nanofiber formation. Affinity studies were conducted between the modified chitosan nano-substrates and the bacillus Calmette-Guérin (BCG) strain of Mycobacterium bovis, the attenuated Mtb-mimic bacteria, for evaluation as mycobacterium capturing substrates. The successful capture of BCG onto the surfaces of the various modified chitosan nanofibers and modified chitosan coated superparamagnetic nanoparticles was confirmed by fluorescence microscopy (FM), light microscopy (LM), transmission electron microscopy (TEM) and field emission scanning electron microscopy (FE-SEM). Analysis of the FM, TEM and FE-SEM images indicated that the chitosan coated nanoparticles functionalized with a C12 aliphatic quaternary ammonium moiety (CS-qC12), captured the most BCG through a combination of ionic and hydrophobic interaction. TMC blended with PVA, to produce nanofibers crosslinked with genipin, were found to have the strongest interaction with BCG of the nanofibrous mats tested. These findings were corroborated by water contact angle measurements, which established that PVA was the least hydrophilic of the non-ionogenic polymers and had hydrogen bond donating groups only, factors influencing the cellular adhesive properties of affinity substrates. / AFRIKAANSE OPSOMMING: Tuberkulose (TB) is een van die wêreld se mees dodelikste siektes, met ‘n derde van die bevolking wat geïnfekteer is daarmee. Ten einde aktiewe TB te diagnoseer moet Mycobacterium tuberculosis (Mtb), die voorsakende patogeen in ʼn monster van die pasiënt se liggaamlike vloeistof, gevind en ïdentifiseer word. Veelvuldige monsters sal die diagnotiese opbrengs verhoog en monster volumes moet dus so groot as moontlik wees wat dikwels ʼn uitdaging vir pasiënte en veral jonger kinders kan bied. Alternatiewelik kan ʼn kleiner monster van die pasiënt vereis word indien daar ʼn manier was om die bakterieë in ʼn monster te konsentreer deur die gebruik van ʼn substraat wat ʼn affiniteit toon vir die patogeniese spesie. Polimere met ʼn intrinsieke sellulêre aktiwiteit, wek belangstelling as sodanige substraat, een synde die natuurlike polisakkaried, chitosan. In hierdie tesis is ʼn verskeidenheid gemodifiseerde chitosan afgeleides voorberei as potensiële Mtb-vaslegging substrate. Dit is gedoen deur chitosan te modifiseer met ʼn verskeidenheid funksionele groepe, gekies op grond van moontlike interaksies met die Mtb selwand, ten einde ʼn verskeidenheid kwaternêre ammonium soute van die chitosan polimeer te bekom. Die kwaternêre chitosan afgeleides is gevolglik gebruik om nano-substrate te sintetiseer wat ʼn affiniteit toon vir Mtb. Polimeer bedekte superparamagnetiese magnetiet nanopartikels (SPMNs) is gesintetiseer via ʼn in situ mede-neerslag metode, waarvolgens die gemodifiseerde chitosan polimere in staat is om met die metaal kern te chelaat. Polimeer nanovesels is ook geëlektrospin deur die elektrospin tegniek te gebruik. Die voorbereide afgeleide N-trimetielammonium chitosan chloried (TMC) is tot nanovesels geëlektrospin deur vermenging met geskikte nie-ionogeniese polimere, naamlik poliviniel-alkohol (PVA), polietilene-oksied (PEO), poliviniel-pirrolidoon (PVP) en poliakrielamied (PAM), wat vereis word ten einde nanovesels te produseer. Affiniteit studies is uitgevoer tussen die gemodifiseerde chitosan nano-substrate en die bacillus Calmette-Guérin (BCG) stam van Mycobacterium bovis, die verswakte Mtb-mimiek bakterieë vir evaluering as mycobakterium-vaslegging substrate. Die suksesvolle vasvang van BCG op die oppervlaktes van die verskillende gemodifiseerde chitosan nanovesels en gemodifiseerde chitosan bedekte SPMNs is bevestig deur fluoressensie mikroskopie (FM), lig mikroskopie (LM), transmissie elektron mikroskopie (TEM) en veld-emissie-skandering elektron mikroskopie (FE-SEM). Analise van die FM, TEM en FE-SEM beelde het getoon dat die chitosan bedekte nanopartikels met byvoeging van ʼn C12 alifatiese kwaternêre ammonium groep, die meeste BCG vasgevang het deur ʼn kombinasie van ioniese en hidrofobiese interaksie. TMC vermeng met PVA om nanovesels te vorm, gekruisbind met genipin, is gevind om die sterkste interaksie met BCG te toon. Hierdie bevindings is bevestig deur water-kontak-hoek-metings, wat getoon het dat PVA die minste hidrofilies van die nie-ionogeniese polimere was en slegs waterstof-binding skenkings groepe het, alles faktore wat die sellulêre bindingskwaliteite van affiniteit-substrate sal beïnvloed.

Thesis (PhD (Med))--University of Stellenbosch, 2011. / ENGLISH ABSTRACT: The nitrogen metabolic pathway is essential for growth and survival of all living organisms including prokaryotes. Certain components of the pathway, such as the enzyme glutamine synthetase (GS), have been studied; however, little information is available regarding the pathway in the mycobacteria. Our in silico studies revealed that many of the components and mechanisms involved in the pathway appear to be conserved between closely related Actinomycetales. Therefore, we investigated three aspects of nitrogen metabolic control in Mycobacterium smegmatis; namely, transcriptional regulation of nitrogen metabolism-related genes, control of enzyme activity and the signalling cascade governing the nitrogen metabolic response. At the transcriptional level, it was found that nitrogen metabolism-related genes were regulated in response to ammonium availability. Two possible transcriptional regulators, AmtR and GlnR, which are the regulators responsible for control of nitrogen-related gene transcription in Streptomyces coelicolor and Corynebacterium glutamicum respectively, were identified in M. smegmatis. Through generation of amtR and glnR deletion mutants, we found that both potential regulators played a role in the control of nitrogen-related gene expression in M. smegmatis. GlnR acted as both an activator and repressor of gene transcription whilst AmtR appeared to activate gene expression which is different to the role its homolog plays in C. glutamicum. On a protein level we found that both GS and glutamate dehydrogenase (GDH) were responsible for ammonium assimilation in M. smegmatis and were regulated in response to ammonium availability. Two GDH isoforms (NAD+- and NADP+-specific) were identified in M. smegmatis and whereas only an NAD+-GDH was detected in M. tuberculosis. The M. tuberculosis GDH also played a largely anabolic role with regard to ammonium assimilation which is in contrast to the belief that ammonium can only be assimilated via GS in this pathogen. The signaling cascade was investigated through generation of a glnD deletion mutant in M. smegmatis. We were able to show that this pivotal protein (GlnD) was able to relay the cellular nitrogen status to the transcriptional machinery as well as to GS. The data presented in this study has advanced our understanding of the nitrogen metabolic pathway in the mycobacteria. Through elucidation of such pathways, our knowledge of mycobacterial physiology and thus infection and survival improves, which could ultimately lead to the discovery of novel mechanisms to aid in the eradication of the disease. / AFRIKAANSE OPSOMMING: Stikstof metabolisme is noodsaaklik vir die oorlewing en groei van alle organismes, prokariote ingesluit. Sekere sellulêre komponente, soos die ensiem glutamine sintetase (GS), is al tevore bestudeer, maar baie min verdere inligting is beskikbaar oor stikstof metabolisme in die mycobacteria. Ons in silico studies het gewys dat baie van die komponente en meganismes gekonserveerd gebly het tussen nou-verwante Actinomycetales. Dus het ons drie aspekte in die beheer van stikstof metabolisme ondersoek; naamlik, die transkriptionele regulering van stikstof metabolisme-verwante gene, die beheer van ensiem aktiwiteit en die sein-meganisme wat die reaksie op stikstof konsentrasie reageer. Op transkripsionele vlak het ons gevind dat stikstof metabolisme-verwante gene gereguleer word in reaksie op stikstof beskikbaarheid. AmtR en GlnR is twee moontlike transkripsie reguleerders wat verantwoordelik is vir transkripsionele beheer in onderskeidelik Streptomyces coelicolor en Corynebacterium glutamicum. Beide hierdie proteïene is geïdentifiseer in M. smegmatis. Deur die konstruksie van amtR en glnR mutante, het ons gevind dat beide potensiële reguleerders ‘n rol gespeel het in die beheer van stikstof-verwante transkripsie in M. smegmatis. GlnR het opgetree as beide ‘n aktiveerder en ‘n onderdrukker van transkripsie terwyl AmtR net ‘n aktiverende rol gespeel het. Die funksie van AmtR in M. smegmatis is dus verskillend van sy homoloog in C. glutamicum. Op proteïen-vlak het ons gevind dat beide GS en glutamaat dehidrogenase (GDH) verantwoordelik was vir die assimilasie van ammonium in M. smegmatis en albei was gereguleer in reaksie op ammonium beskikbaarheid. Twee vorme van GDH (NAD+- spesifieke- en NADP+-spesifieke GDH) was geïdentifiseer in M. smegmatis terwyl net ‘n NAD+- spesifieke GDH in M. tuberculosis gevind is. Die M. tuberculosis GDH het ook ‘n anaboliesie rol gespeel met betrekking tot ammonium assimilasie wat in teenstelling is met die huidige opvatting dat ammonium alleenlik deur GS ge-assimileer kan word. Die sein-meganisme is ondersoek deur ‘n glnD M. smegmatis mutant te konstrueer. Ons het bewys dat hierdie deurslaggewende proteïen (GlnD) die sellulêre stikstof status aan die transkripsionele masjinerie, en aan GS kon oordra. Die data wat in hierdie studie voorgelê word, het ons kennis van stikstof metabolisme in die mycobacteria gevorder. Sodanige metaboliese studies verbreed ons kennis van mycobacteriële fisiologie en dus M. tuberculosis infeksie en oorlewing en kan uiteindelik lei tot die ontdekking van unieke teiken meganismes om te help met die beheer van die siekte en nuwe middelontwikkeling.

Thesis (PhD)--Stellenbosch University, 2002. / ENGLISH ABSTRACT: Pathogenic organisms frequently utilize proteases to perform specific functions related to virulence. There is little information regarding the role of proteolysis in Mycobacterium tuberculosis and no studies on the potential involvement of these enzymes in the pathogenesis of tuberculosis. The present study initially focused on the characterization of a family of membrane anchored, cell wall associated, subtilisin-like serine proteases (mycosins-1 to 5) of Mycobacterium tuberculosis. These proteases were shown to be constitutively expressed in M. tuberculosis, to be located in the cell wall of the organism and to be potentially shed (either actively or passively) from the wall. Relatively high levels of gamma interferon secretion by T-cells in response to these proteases were observed in Mantoux positive individuals. The absence of any detectable protease activity lead to a protein sequence analysis which indicated that the mycosins are probable mycobacterial-specific proprotein processing proteases. To identify possible substrates for these proteases, the genome sequence regions surrounding the mycosin genes were analyzed. This revealed that the mycosin genes are in fact part of a cluster of 6 to 12 genes which have been duplicated multiple times in the genome of M. tuberculosis. Due to the presence of members of the previously described ESAT-6 T-cell antigen family within this duplicated region, the five gene cluster regions were named the ESAT-6 loci. In silico analysis of finished and unfinished genome sequencing data revealed the presence of orthologues of the Mycobacterium tuberculosis H37Rv ESAT-6 loci in the genomes of other mycobacteria, e.g. M. tuberculosis CDC1551, M. tuberculosis 210, M. bovis, M. leprae, M. avium, and the avirulent strain M. smegmatis. Phylogenetic analyses done on the resulting sequences have established the duplication order of the gene clusters and demonstrated that gene cluster region 4 (Rv3444c-3450c) is ancestral. Region 4 is also the only region for which an orthologue could be found in the genomes of Corynebacterium diptheriae and Streptomyces coelicoior. Thus, the comparative genomic analyses revealed that the presence of the ESAT-6 gene cluster seems to be a unique characteristic shared by members of the high G+C gram-positive bacteria and that multiple duplications of this cluster have occurred and have been maintained only within the genomes of members of the genus Mycobacterium. The ESAT-6 gene cluster regions were shown to consist of the members of the ESAT-6 gene family (encoding secreted T-cell antigens that lack detectable secretion signals), the mycosins (secreted, cell wall-associated subtilisin-like serine proteases) as well as genes encoding putative ABC transporters, ATP-binding proteins, and other membrane-associated proteins. Thus, from the observation that members of the ESAT-6 family are secreted without the normal sec-dependent secretion signals, it was hypothesized that the membrane-associated and energy-providing proteins function together to form a transport system for the secretion of the members of the ESAT-6 protein family. Supporting this hypothesis, one of the ESAT-6 gene clusters was shown to be expressed as a single polycistronic RNA, forming an operon structure. The promoter for this operon, P e s r e g 3. was also identified and its activity characterized. Subsequent secretion analyses results have shown that secretion of members of the ESAT-6 protein family is dependent on the presence of the proteins encoded by the ESAT-6 gene cluster regions, confirming the putative transport-associated functions of the ESAT-6 gene cluster-encoded proteins. The mycobacterial ESAT-6 gene clusters contain a number of features of quorum sensing and lantibiotic operons, and an extensive review of the literature have led to the hypothesis that the members of the ESAT-6 family may be secreted as signaling molecules and may be involved in the regulation of expression of genes during intracellular residence of the bacterium. In the final part of this study, the evolutionary history of the PE and PPE gene families (members of which is found situated in the ESAT-6 gene clusters) were investigated. This investigation revealed that the expansion of these families are linked to the duplications of the ESAT-6 gene clusters, which is supported by the absence of the multiple copies of the PE and PPE families in the genome of the fast-growing mycobacterium M. smegmatis. Furthermore, dot blot analyses showed that the PPE gene present in ESAT-6 gene cluster region 5 is able to distinguish between mycobacteria belonging to the slow-growing or fast-growing species, indicating a function for the genes of these two families and/or the ESAT-6 gene clusters in the phenotypical differences distinguishing these two groups of mycobacteria. In conclusion, this study has highlighted numerous important aspects of mycobacterial genomics and has greatly contributed to the current body of knowledge concerning the role of proteases, gene duplication and mechanisms of antigen expression and secretion in M. tuberculosis. / AFRIKAANSE OPSOMMING: Sien asb volteks vir opsomming

Dissertation (PhD)--University of Stellenbosch, 2006. / ENGLISH ABSTRACT: Children contribute little to disease transmission and the maintenance of the tuberculosis epidemic, but they constitute a significant proportion of the total tuberculosis (TB) caseload and experience considerable morbidity and mortality in endemic areas, despite the availability of cheap and effective treatment. The difficulty of diagnosing childhood tuberculosis is one of the major obstacles that hinder the provision of antituberculosis treatment to children in endemic areas. The diagnosis of childhood tuberculosis is complicated by the lack of a practical gold standard, as bacteriologic specimens are difficult to collect and the yield is low. In non-endemic countries the diagnosis of childhood tuberculosis is based on the triad of: 1) exposure to an adult index case, 2) a positive tuberculin skin test, and 3) suggestive radiographic signs. However, the triad has limited value in endemic areas where exposure to and/or infection with Mycobacterium tuberculosis is common, and chest radiography is rarely available. The objective of this dissertation was to address the diagnostic dilemma faced by health professionals in endemic areas with limited resources, where children currently have poor access to chemoprophylaxis and antituberculosis treatment. We first clarified basic disease concepts, through a critical review of the pre-chemotherapy literature that documented the natural history of childhood tuberculosis. Three central concepts were identified; 1) the importance of accurate case definition, 2) the relevance of risk stratification, and 3) the diverse spectrum of disease, which necessitates accurate disease classification. The importance of accurate case definition is illustrated by the fact that isolated hilar adenopathy, considered the principal radiographic sign of primary tuberculosis, becomes transiently visible in the majority of children following recent primary infection. Our analysis of the natural history of childhood tuberculosis allowed accurate quantification of the risk to progress to disease following primary infection with M.tuberculosis. This demonstrated that the risk depends mainly on the age and/or immune-status of the child, the time since primary infection occurred and the presence or absence of symptoms. After analysing these historic studies, we proceeded to document the burden of childhood tuberculosis in an endemic area. We first conducted a retrospective study to describe current diagnostic practices and demonstrated almost exclusive reliance on chest radiography. We then calculated the burden of childhood tuberculosis in a prospective descriptive study. The corrected tuberculosis incidence rate in children was 407/100 000/year and children with severe forms of disease, such as disseminated (miliary) tuberculosis and/or tuberculous meningitis, were rarely recorded in the TB treatment register used for routine community-based surveillance. An additional obstacle to progress in the field of childhood tuberculosis has been the lack of standard descriptive terminology. Following a careful review of the literature, we proposed a radiological classification of childhood intra-thoracic tuberculosis and explored the different pathologic mechanisms that underlie these diverse disease manifestations. We then conducted a prospective descriptive study to document the disease spectrum in children treated for tuberculosis in an endemic area. The disease patterns observed were consistent with those described in the pre-chemotherapy literature. In addition, we demonstrated that bacteriologic confirmation may be achieved in the majority of children with intra-thoracic tuberculosis, in highly endemic settings. Finally we developed a novel symptom-based approach to diagnose pulmonary tuberculosis in children from endemic areas with limited resources. We followed a step-wise approach by first conducting a community-based survey to document the prevalence of symptoms traditionally associated with tuberculosis in a random selection of children from an endemic area. The survey demonstrated that poorly defined symptoms offer poor diagnostic value. The second step was to evaluate the diagnostic value of well-defined (persistent, non-remitting) symptoms in a small prospective study. Well-defined symptoms demonstrated good diagnostic value, but these promising results required further validation. As a final step, we validated the diagnostic value of a novel symptom-based approach in a large prospective, community-based study. In this study, a simple symptom-based approach diagnosed childhood pulmonary tuberculosis with a remarkable degree of accuracy, particularly in HIV-uninfected children older than 3 years of age. This novel diagnostic approach offers the exciting prospect of extending antituberculosis treatment to children in endemic areas with limited resources, where current treatment access is poor. / AFRIKAANSE OPSOMMING: Tuberkulose beheer programme plaas feitlik geen klem op die behandeling van kinders nie, omdat kindertuberkulose selde aansteeklik is en die persepsie bestaan dat kinders slegs in raar gevalle ernstig siek word. Tuberkulose lewer egter ‘n betekenisvole bydrae tot kindermorbiditeit en mortaliteit in endemiese areas, terwyl dit ‘n maklik behandelbare siekte is. Kindertuberkulose is moeilik om te diagnoseer en dit is ‘n belangrike faktor wat daartoe bydra dat kinders dikwels nie antituberkulose behandeling ontvang wanneer hulle dit benodig nie. Die diagnose van kindertuberkulose is moeilik, omdat die organisme selde aangetoon kan word. In nie endemiese areas word kindertuberkulose dikwels gediagnoseer na aanleiding van: 1) blootstelling aan ‘n volwasse indeks geval, 2) ‘n positiewe tuberkulien veltoets, en 3) die teenwoordigheid van radiologiese tekens suggestief van tuberkulose. Hierdie benadering het defnitiewe tekortkominge in endemiese areas, waar blootstelling aan en infeksie met Mycobacterium tuberculosis algemeen is. Gevolglik berus die diagnose van kindertuberkulose hoofsaaklik op die subjektiewe interpretasie van die borskasplaat, wat welbekende tekortkominge het en verder is radiologiese toetse dikwels nie beskikbaar in hierdie areas nie. Die doel van die navorsingsprojek was om die dilemma rondom die diagnose van kindertuberkulose in endemiese areas aan te spreek. Eerstens is basiese siektekonsepte uitsorteer deur ‘n kritiese oorsig van studies uit die pre-chemoterapie era. Hierdie kosbare studies het die natuurlike verloop van tuberkulose in kinders beskryf, nog voordat antituberkulose middels beskikbaar was. Drie sentrale konsepte is geidentifiseer; 1) die belang van akkurate siekte definisie, 2) die relevansie van risiko stratifikasie en 3) die diverse spektrum van patologie wat akkurate siekte klassifikasie noodsaak. Die belang van akkurate siekte definisie word geïllustreer deur die feit dat geïsoleerde hilêre adenopatie ‘n verbygaande verskynsel is in die meerderheid van kinders kort na primêre infeksie. Ons analise het daarop gefokus om die risiko om siekte te ontwikkel nadat primêre infeksie met M.tuberculosis plaasgevind het, te kwantifiseer. Die hoof risiko faktore was; 1) die ouderdom en/of immuunstatus van die kind, 2) die tydsverloop sedert infeksie, en 3) die teenwoordigheid van simptome al dan nie. Hierna het ons die siektelas wat tuberkulose vandag op kinders in endemiese areas plaas gedokumenteer. Ons het eers die huidige diagnostiese praktyke geëvaluaeer in ‘n retrospektiewe studie en toe ‘n prospektiewe beskrywende studie gedoen om die siektelas so akkuraat as moontlik te meet. Die insidensie van kindertuberkulose was hoog (>400/100 000/jaar), selfs na korreksie vir kinders wat ontoepaslik behandeling ontvang het. Verder is gevind dat die meerderheid van kinders met ernstige siekte toestande soos miliêre tuberkulose en/of meningitis, nie in roetine moniterings data reflekteer word nie. ‘n Bykomende struikelblok in kindertuberkulose is die gebrek aan standaard beskrywende terminologie. Om dit te bevorder ontwikkel ons ‘n nuwe radiologiese klassifikasie van intra-torakale kindertuberkulose en beskryf ons die verskillende patologiese meganismes onderliggend tot hierdie uiteenlopende siektebeelde. Daarna dokumenteer ons die volledige spektum van kindertuberkulose in ‘n endemiese area en demonstreer dat die siektepatrone wat ons vandag observeer soortgelyk is aan die wat in die pre-chemoterapie literatuur beskryf is. Ons toon ook dat bakteriologiese bevestiging moontlik blyk te wees in die meerderheid van kinders wat vir intra-torakale tuberkulose behandel word in endemiese areas. Nadat ons duidelikheid verkry het oor die basiese siektekonsepte, siekte klassifikasie en die siektelading in ons omgewing, kon ons op die ontwikkeling van ‘n simptoom-gebaseerde benadering tot die diagnose van kindertuberkulose fokus. Ons het ‘n stapsgewyse benadering gevolg. Die eerste stap was om die voorkoms van simptome wat gebruiklik met tuberkulose vereenselwig word te dokumenteer in ‘n ewekansige groep kinders. Die gemeenskapsopname het getoon dat swak gedefiniëerde simptome swak diagnostiese waarde bied. Die tweede stap was om vas te stel of verbeterde simptoom definisie die diagnostiese waarde kan verbeter. ‘n Klein prospektiewe studie het getoon dat goed gedefiniëerde simptome (persisterende simptome van onlangse aankoms) goeie diagnostiese waarde bied. Die finale stap was om hierdie belowende benadering formeel te toets in ‘n groot prospektiewe, gemeenskapsgebaseerde studie. Hierdie studie het getoon dat ‘n eenvoudige simptoom-gebaseerde benadering pulmonale tuberkulose met goeie akkuraatheid kan diagnoseer, veral in HIV-ongeïnfekteerde kinders wat ouer is as 3 jaar. Hierdie nuwe diagnostiese benadering bied die moontlikheid om antituberkulose behandeling te voorsien aan kinders in endemiese areas wat tans feitlik geen behandeling ontvang nie.

published_or_final_version / Paediatrics and Adolescent Medicine / Master / Master of Philosophy