Leucine-included liquid diet as medical nutrition therapy improved handgrip strength and mid-upper circumference in clinically malnourished pulmonary tuberculosis patient with high neutrophil lymphocyte ratio
A case report from Universitas Indonesia hospital
Abstract
Background and objectives: Muscle weakness delays clinical improvement in pulmonary tuberculosis patients. Higher neutrophil lymphocyte ratio, low handgrip strength, mid-upper arm circumference indicates bad clinical outcome. Weight loss must be managed from the start of treatment. Good muscle condition has benefits to the recovery rate. Leucine provides benefits in increasing the synthesis of muscle mass so as the clinical conditions. Unfortunately, leucine has not been the routine part of medical nutrition therapy in tuberculosis patients. Methods: This is a case report of a female patient with body weight 42 kg and height 150 cm, admitted to Universitas Indonesia Hospital, with lung tuberculosis. Leucine given, started from 1.95 g/day to the maximum amount of 7,34 g/day through the hospital tailored-made liquid food. There was an improvement of clinical signs and symptoms during 14 days of hospitalization. Mid-upper arm circumferences at day 1, 8, and 15 were 21.1, 21.4, and 12.9 21.9 cm in a row. The right and left handgrip strength at day 1, 8, and 15 were 9.7 kg and 8.1 kg, 10.9 kg and 8.9 kg, 15.1 kg and 13.4 kg, respectively. While the neutrophil lymphocyte ratio at day 0, 6, and 9 were increasing, at 6.89, 6.89, and 13.8, in a row. Conclusions: Leucine 1.95–7.34 g/day, in tailored-made liquid food, as part of tuberculosis management therapy, though the NLR 13.8, can improve the mid-upper arm circumference, handgrip strength, clinical signs and symptoms in 14 days of hospitalization.Downloads
References
Kementerian Kesehatan RI. Program Penanggulangan Tuberkulosis 2022. Jakarta: Kementerian Kesehatan RI; 2023.
Carwile ME, Hochberg NS, Sinha P. Undernutrition is feeding the tuberculosis pandemic: a perspective. J Clin Tuberc Other Mycobact Dis 2022;27:1-6.
Dryburgh L, Rippin H, Malykh R. Tuberculosis and malnutrition. World Health Organization; 2024.
Skupien EC, Lazzari TK, Coutinho SE, Silva DR. The relation between leptin and inflammatory markers with respiratory and peripheral muscle strength in tuberculosis: a case-control study. Clin Respir J 2018;12:2559-65.
Volpi E. Is leucine content in dietary protein the key to muscle preservation in older women? Am J Clin Nutr 2018;107:143–4.
Karakousis ND, Gourgoulianis KI, Kotsiou OS. Sarcopenia and tuberculosis: is there any connection. J Pers Med 2023;13:1102-3..
Diallo A, Dahourou DL, Dah TTE, Tassembedo S, Sawadogo R, Meda N. Factors associated with tuberculosis treatment failure in the Central East Health Region of Burkina Faso. Pan Afr Med J 2018;30:293-4.
Paton NI, Ng YM. Body composition studies in patients with wasting associated with tuberculosis. Nutrition 2006;22:245–51.
Jacob JJ, Paul PAM. Infections in endocrinology: tuberculosis. In: Feingold KR, Anawalt B, Blackman MR, editors. South Dartmouth: MDText.com, Inc.; 2000.
Kiryukhina L, Sysoeva V, Denisova N, Nefedova N, Archakova L, Yablonskii P. Association lung function disorders and the respiratory muscles strength in patients with tuberculosis (TB) and COPD. Eur Respir J 2018;32:191-9.
Kumar NP, Nancy AP, Moideen K, Menon PA, Banurekha VV, Nair D, et al. Low body mass index is associated with diminished plasma cytokines and chemokines in both active and latent tuberculosis. Front Nutr 2023;10:101-12.
PrayGod G, Range N, Faurholt-Jepsen D, Jermiah K, Faurholt-Jepsen M, Aabye MG, et al. Weight, body composition and handgrip strength among pulmonary tuberculosis patients: a matched cross-sectional study in Mwanza, Tanzania. Trans R Soc Trop Med Hyg 2011;105:140-7.
Choi CJ, Choi WS, Kim CM, Lee SY, Kim KS. Risk of sarcopenia and osteoporosis in male tuberculosis survivors: Korea National Health and Nutrition Examination Survey. Sci Rep 2017;7:123-31.
Rondanelli M, Nichetti M, Peroni G, Faliva MA, Naso M, Gasparri C, et al. Where to find leucine in food and how to feed elderly with sarcopenia in order to counteract loss of muscle mass: practical advice. Front Nutr 2021;7:391-401.
Mero A. Leucine supplementation and intensive training. Sports Med 1999;27:347–58.
Borack MS, Volpi E. Efficacy and safety of leucine supplementation in the elderly. J Nutr 2016;146:2625-9.
Luc C, Dennis B, Motoni K, Sidney M, Andrew R. A proposal for an upper limit of leucine safe intake in healthy adults. Am Soc Nutr 2012;149:2249-50.
Elango R. Tolerable upper intake level for individual amino acids in humans: a narrative review of recent clinical studies. Adv Nutr 2023;14:885-94.
Pencharz PB, Elango R, Ball RO. Determination of the tolerable upper intake level of leucine in adult men. J Nutr 2012;142:2220-4.
Rasmussen B, Gilbert E, Turki A, Madden K, Elango R. Determination of the safety of leucine supplementation in healthy elderly men. Amino Acids 2016;48:1707–16.
Aytac S, Ovayolu O, Dogru S. The effect of breathing exercises on fatigue in tuberculosis patients: a randomized controlled trial. Rev Assoc Med Bras 2024;70:180-7.
Nicastro H, Carvallho M, Barquilha G, Ferreira LS. Leucine supplementation: a possible anti-inflammatory strategy evidences from a pilot study. SL Nutr Metab 2017;1:114-8.
Al-Shaer MH, Elewa H, Alkabab Y, Nazer LH, Heysell SK. Fixed-dose combination associated with faster time to smear conveersion compared to separate tablets of anti-tuberculosis drugs in patients with poorly controlled diabetes and pulmonary tuberculosis in Qatar. BMC Infect Dis 2018;18:281-7.
Huang Y, Ao T, Zhen P, Hu M. Neutrophil-to-lymphocyte ratio and its association with latent tuberculosis infection and all-cause mortality in the US adult population: a cohort study from NHANES 2011–2012. Front Nutr 2024;11:1-9.
Sormin D, Siagian P, Sinaga BYM, Eyanoer PC. Neutrophil lymphocyte ration in tuberculosis patients and multidrug resistant tuberculosis patients. J Respirol Indones 2018;38:177-80.
Yin Y, Kuai S, Liu J, Zhang YY, Shan Z, Gu L, Huang Q, et al. Pretreatment neutrophil-to-lymphocyte ratio in peripheral blood was associated with pulmonary tuberculosis retreatment. Arch Med Sci 2017;13:404-11.
Gu Z, Liu B, Yu X, Cheng T, Han T, et al. Association of blood neutrophil-lymphocyte ratio with short-term prognosis and severity of tuberculosis meningitis patients without HIV infection. BMC Infect Dis 2023;23:1-7.
Yallamraju SR, Mehrotra R, Sinha A, Gattumeedhi SR, Gupta A, Khadse SV. Use of mid upper arm circumference for evaluation of nutritional status of OSMF patients. J Int Soc Prev Community Dent 2014;4:122–5.
Gibson RS. Principles of nutritional assessment. 2nd edition. New York: Oxford University Press; 2005.
Tungdim MG, Kapoor AK. Nutritional status and chronic disease among the adult tribal population of northeast India. Open Anthropol J 2010;3:188-91.
Chhabra S, Kashyap A, Bhagat M, Mahajan R, Sethi S. Anemia and nutritional status in tuberculosis patients. Int J Appl Basic Med Res 2021;11:226–30.
Thorup L, Hamann SA, Kallestrup P, Hjortdal VE, Tripathee A, Neupane D, et al. Mid-upper arm circumference as an indicator of underweight in adults: a cross-sectional study from Nepal. BMC Public Health 2020;20:1-7.
Praygod G, Range N, Jepsen DF, Jeremiah K, Jepsen MF, Aabye MG, et al. Daily multi-micronutrient supplementation during tuberculosis treatment increases weight and grip strength among HIV-uninfected but not HIC-infected patients in Mwanza, Tanzania. J Nutr 2011;141:685-91.
Reus YAD, Beek LT, Werf TSVD, Akkerman OW. Changes in body composition and strength during initial treatment in malnourished patients with tuberculosis. Eur Respir J 2019;54:267-9.
Mishra P, Bhargava S, Vihan S. Handgrip strength deficit and time lag between symptom onset and starting of chemotherapy in pulmonary tuberculosis: a cross-sectional study in North India. Physiol Pharmacol 2023;67:205–11.
Heo R, Kim TH, Jeong JH, Heo M, Ju SM, Yoo JW, et al. Association of nutritional intake with physical activity and handgrip strength in individuals with airflow limitation. Tuberc Respir Dis 2025;88:120-9.
Mishra P, Verma VK, Meenu M, Mohan A, Bhatia J, Arya SD. Association of body mass index, hand grip strength and quality of life with response to anti-tubercular therapy in adult patients of pulmonary and extrapulmonary tuberculosis. Int J Basic Clin Pharmacol 2021;10:1297-307.
Chung Y, Park Y, Park H, Jeoun HY, Kang YA. Association of physical inactivity and handgrip strength with non-tuberculous mycobacterial pulmonary disease. Int J Tuberc Lung Dis 2024;28:367-73.
Hale G, Adzemovid T, Hullsiek KH, Mulwana S, Ndyetukira JF, et al. Mid-upper arm circumference is a strong predictor of mortality among Ugandan adults with HIV-associated cryptococcal meningitis: a prospective cohort study. Open Forum Infect Dis 2024;20:1-8.
Wamiti J, Makau WK, Onyango F, Ngala S. Leucine supplementation in the management of protein energy malnutrition: a review article. East Afr Med J 2016;93:20-4.
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