IJTID Vol 8 No 2 May-Agustus 2020_NEWfromSARAH.indd Vol. 8 No. 2 May–August 2020 Copyright © 2020, IJTID, p-ISSN 2085-1103, e-ISSN 2356-0991 Available online at IJTID Website: https://e-journal.unair.ac.id/IJTID/ Research article Diff erences of Interleukin-18 and Interleukin-10 Levels in Pulmonary Rifampicin Resistant dan Rifampicin Sensitive Tuberculosis Patients in Dr. Soetomo Hospital Surabaya Audrey Gracelia Riwu1a, Jusak Nugaraha2, Yoes Prijatna Dachlan3 1Department of Immunology Postgraduate School, Universitas Airlangga, Surabaya, East Java, Indonesia 2Department of Clinical Pathology, Faculty of Medicine Universitas Airlangga, Dr. Soeotomo Hospital Surabaya,East Java, Indonesia 3Department of Parasitology, Faculty of Medicine Universitas Airlangga, Surabaya, East Java, Indonesia Received: 1st January 2019; Revised: 14th March 2019; Accepted: 19th December 2019 ABSTRACT Rifampicin is an anti-tuberculosis drug used in short-term treatment regimen for tuberculosis (TB) patients. Resistance to rifampicin causes the prolonged duration of tuberculosis treatment. Interleukin-18 (IL-18) is a pro-infl ammatory cytokine which acts in controlling the growth of M. tuberculosis, while Interleukin-10 (IL-10) is an anti-infl ammatory cytokine which acts in limiting tissue damage and maintain tissue homeostasis. IL-18 and IL-10 is important in explaining the diff erent degrees of infl ammation (mild, moderate and severe) in rifampicin-resistant (RR) and rifampicin-sensitive (RS) pulmonary TB patients. The purpose of this study is to determine diff erent levels of IL-18 and IL-10 in new TB patients with RR and RS. A retrospective cohort study with a cross-sectional design. 50 subjects were examined and grouped into two groups, namely pulmonary TB with RR (n = 25) and pulmonary TB with RS (n = 25). IL-18 and IL-10 were measured using the ELISA Method. Diff erences in IL-18 and IL-10 levels between groups were analyzed using the Mann-Whitney test. The mean level of IL-18 (pg/ml) in RR and RS pulmonary TB patients were 1273.53±749.86 and 787.96 ±589.28 respectively. The mean level of IL-10 (pg/ml) in RR and RS pulmonary TB patients were 125.25±118.32 and 128.81±135.77 respectively. The mean level of IL-18 in RR and RS pulmonary TB patients were found to have a signifi cant diff erence, while the mean level of IL-10 did not have a signifi cant diff erence. This circulating level of IL-18 and IL-10 can be used as a marker of infl ammation degrees in pulmonary RR-TB and RS-TB patient. Keywords: Interleukin-18, Interleukin-10, Tuberculosis, Rifampicin Resistant, Rifampicin Sensitive ABSTRAK Rifampisin adalah rejimen dasar pengobatan jangka pendek untuk penderita tuberculosis (TB). Resistensi terhadap rifampisin menyebabkan durasi pengobatan tuberculosis menjadi lebih lama. Interleukin-18 (IL-18) adalah sitokin Proinfl amsi yang berperan dalam mengontrol pertumbuhan M. tuberculosis, sedangkan Interleukin 10 (IL-10) adalah sitokin anti-infl amasi yang berperan membatasi kerusakan jaringan dan mempertahankan homeostatis jaringan. IL-18 dan IL-10 berperan penting untuk menjelaskan derajat infl amasi (ringan, sedang dan berat) yang berbeda pada penderita TB paru dengan rifampicin resistant (RR-TB) dan rifampcin sensitive (RS-TB). Tujuan penelitian ini adalah mengetahui perbedaan kadar IL-18 dan IL-10 pada penderita RR-TB dan RS-TB. Penelitian ini merupakan penelitian cohort retrospektif dengan rancangan cross-sectional. Sebanyak 50 subjek penelitian diperiksa dan dikelompokkan menjadi dua kelompok yaitu kelompok RR-TB (n=25) dan kelompok RS-TB (n=25). Pemeriksaan IL-18 dan IL-10 dilakukan dengan Metode ELISA. Perbedaan kadar IL-18 dan IL-10 antara kelompok dianalisis menggunakan Mann-whitney. Rerata kadar IL-18 (pg/ml) pada penderita RR-TB dan RS-TB adalah 1273.53±749.86 dan 787.96±589.28. Rerata kadar IL-10 (pg/ml) pada penderita RR-TB dan RS-TB adalah 125.25±118.32 dan 128.81±135.77. Rerata kadar IL-18 pada penderita RR-TB dan RS-TB ditemukan memiliki perbedaan signifi kan, sedangkan rerata kadar IL-10 pada penderita RR-TB dan RS-TB tidak * Corresponding Author: riwuaudrey@gmail.com 117Audrey Gracelia Riwu, et al.: Differences of Interleukin-18 and Interleukin-10 Levels Copyright © 2020, IJTID, p-ISSN 2085-1103, e-ISSN 2356-0991 memiliki perbedaan yang signifi kan. Nilai kadar IL-18 dan IL-10 ini dapat digunakan sebagai penanda derajat infl amasi pada penderita RR-TB dan RS-TB. Kata Kunci: Interleukin-18, Interleukin-10, Tuberculosis, Rifampicin Resistant, Rifampicin Sensitive How to Cite: Riwu, Audrey Gracelia., Nugaraha, Jusak., Dachlan, Yoes Prijatna. Diff erences of Interleukin-18 and Interleukin-10 Levels in Pulmonary Rifampicin Resistant dan Rifampicin Sensitive Tuberculosis Patients in Dr. Soetomo Hospital Surabaya. Indonesian Journal of Tropical and Infectious Disease, 8(2), 1–8 INTRODUCTION In 2018, The World Health Organization (WHO) was stated that Tuberculosis (TB) is one of the top ten causes of death worldwide. About 10.4 million people suffer from TB and 1.7 million people die from this disease. More than 95% of deaths from TB occur in low and middle- income countries. India, Indonesia, China, the Philippines, Pakistan, Nigeria, and South Africa are countries that accounted the most cases of TB.1 According to the Basic Health Research of Indonesia the prevalence of patients diagnosed with TB in 2013 was 0.4% with the fi ve highest provinces which are West Java, Papua, DKI Jakarta, Gorontalo, Banten and West Papua. Of the entire population diagnosed with TB, only 44.4% were treated with a program medicines.2 Rifampicin Resistant is defi ned as a TB case that is declared resistant to rifampicin. TB strains resistant to rifampicin may be either sensitive or also resistant to isoniazid, which for the latter is considered as Multidrug Resistant-Tuberculois (MDR-TB) based on the GeneXpert test results. This is due to the lower mutation rate of isoniazid (2.56 x 108 CFU / ml M. tuberculosis colonies) compared to the mutation rate of rifampicin (6 x 1010 CFU / ml M. tuberculosis colonies), so that it can be said that TB patients that are resistant to the rifampicin drug are also resistant to isoniazid, but this comparison varies greatly between countries and patient groups.3,4 Rifampicin is an antibiotic that has efficient antimicrobial action which combined with isoniazid which considered to be the basis of a short-term treatment regimen for TB. Rifampicin in M. tuberculosis targets the RNA polymerase β-subunits by binding and inhibiting the extension of RNA messenger. The role of rifampicin is to inhibit active growth and slow metabolism (slow-growing) of bacilli.3 Interleukin-18 (IL-18) was fi rst described and used in rat serum which was intraperitoneally inoculated with endotoxin and was referred to as “Interferon-gamma (IFN- ) inducing factor”.5 Inside the human body, IL-18 is constitutively expressed by several cells, namely macrophages, kupff er cells, keratinocytes, osteoblasts, adrenal cortex cells, intestinal epithelial cells, microglial cells, and synovial fi broblasts.6 IL-18 is a pro- infl ammatory cytokine that works synergistically with Interleukin-12 (IL-12) to induce IFN- production. The expression of IL-18 is regulated in chronic infl ammatory diseases mediated by Th1. IL-18 can also contribute to the protection against mycobacteria. It is found that rats with IL-18 defi ciency also have a decrease in IFN- levels.7 Interleukin-10 (IL-10) is an anti-infl ammatory cytokine which has a crucial role in preventing inflammatory, pathological autoimmune8 and allergies.9 Defi ciency or decreased expression of IL-10 can increase the infl ammatory response to microbes but on the other hands, it can also cause the development of infectious diseases such as TB and several of autoimmune diseases.8 IL-10 can also increase the continuity of M. tuberculosis and its growth in macrophages by suppressing the partial maturation of phagosomes which depend on the activity of the signal transducer and activator of transcription 3 (STAT3)10. Currently, IL-10 increases survival and intracellular growth Mycobacteria by suppressing innate and adaptive immune responses.11 This study will describe how diff erent levels of IL-18 and IL-10 in pulmonary TB patients with rifampicin resistant and rifampicin sensitive, 118 Copyright © 2020, IJTID, p-ISSN 2085-1103, e-ISSN 2356-0991 Indonesian Journal of Tropical and Infectious Disease, Vol. 8 No. 2 May–August 2020: 116–123 where IL-18 and IL-10 can play an important role in explaining the diff erent degrees of infl ammation between these two groups. MATERIALS AND METHODS Study Population This study was conducted in the Department of Clinical Pathology, Dr. Soetomo Hospital from August to November 2018. This study included 50 patients who were selected from the TB- DOTS/MDR Clinic of Dr. Soetomo Hospital. The study protocol has been approved by the Ethical Review Committee of Dr. Soetomo Hospital (0488/KEPK/VIII/2018). The data of all patients were collected after taking informed consent from patients. The age of patients ranged from 17 to 75 years old. The patients were assigned into two groups. The fi rst group consisted of 25 patients with rifampicin-resistant pulmonary TB and the second group also consisted of 25 patients with rifampicin-sensitive pulmonary TB. Patients with HIV-AIDS, hepatitis, autoimmune diseases, diabetes mellitus, liver and kidney disease were excluded from this study. Also, patients treated with corticosteroid or immunosuppressive drugs were excluded, along with patients who had received anti-tuberculosis for more than one month because it can cause bias in the results of the examination Sample Preparation Four milliliters of blood were drawn aseptically from the basilic vein of each patient. Blood specimens were collected by using vacutainer venipuncture then stored in the serum separator tube. The tube contains a separation gel in the base of the tube which separates the serum from the whole blood. The blood sample was collected then was centrifuged at 3000 rpm for 10 minutes, the serums were then stored and freeze at -80°C for further use. Enzyme-linked Immunosorbent Assay (ELISA) Analysis The frozen serums were thawed at room temperature and cytokine IL-18 and IL-10 levels were then measured using the Human Sandwich-ELISA kit from Elabscience® done as the manufactures instructions. The cytokine concentrations in samples were calculated using the standard curve generated from recombinant cytokines, and the results are expressed in picograms per milliliter (pg/ml). Statistical Methods The result is presented as the mean ± s.d. Statistical signifi cance was calculated by the Mann-Whitney test to see diff erences between IL- 18 and IL-10 in patients with pulmonary RR-TB and pulmonary RS-TB. The p values< 0.05 were considered statistically signifi cant. RESULTS AND DISCUSSION Clinical Characteristics of Subjects The clinical characteristics of the 25 patients with pulmonary RR-TB and 25 patients with pulmonary RS-TB are summarized in Table 1. The clinical type of all TB patients were all pulmonary TB. IL-18 Level The highest level of IL-18 found in pulmonary RR-TB patients was 2486 pg/ml, and the lowest 58.39 pg/ml, while the highest level of IL-18 in pulmonary RS-TB patients was 1990 pg/ml and the lowest was 106.06 pg/ml. The mean, standard deviation, and p-values of IL-18 levels in these two groups are shown in Table 2. The mean level of IL-18 between pulmonary RR-TB and RS-TB patients were showed signifi cant diff erences (p <0.05). The diff erences of IL-18 in pulmonary RR-TB and pulmonary RS-TB patients are shown in the boxplot in Figure 1. Table 1. Clinical Characteristics of the Population Studied. Pulmonary RR-TB Pulmonary RS-TB Gender, male/female 18/7 11/14 Median age (range) 37.00 (23-67) 43.00 (18-63) 119Audrey Gracelia Riwu, et al.: Differences of Interleukin-18 and Interleukin-10 Levels Copyright © 2020, IJTID, p-ISSN 2085-1103, e-ISSN 2356-0991 The IL-18 level between pulmonary RR-TB and RS-TB patients found in this study has a mean of 1273.53 ± 749.86 pg/ml and 787.96 ± 589.28 pg/ml respectively. This shows that the increasing level of IL-18 in the blood was found to be signifi cantly higher in pulmonary RR-TB than in pulmonary RS-TB. This results in this study also in accordance with the result of Wang et al12 study. Wang et al12 also stated that the IL-18 serum was found to be higher in patients with pulmonary RR-TB (131.03 ± 94.92) compared to drug sensitive TB (94.28 ± 57.10) and healthy controls (61.66 ± 24.78). The resistance to rifampicin in TB is caused by mutations in the bacterial chromosome (rpo gene). Mutations in this gene will cause changes in the structure and activity of drug targets that results in generating bacterium M. tuberculosis that cannot be eliminated using rifampicin which has an impact on increasing the number of said bacteria in the host body.13 This increase in the number of bacteria causes macrophages as a fi rst- line defense against the invasion of these bacteria and mediates the innate immune response through the introduction of pathogens and an increase in infl ammatory reactions. Increased macrophage activation in RR pulmonary TB infection will increase the production of proinflammatory cytokines that play a role for the mechanism of killing M. tuberculosis.14 Rifampicin plays an important role in TB treatment because of its bactericidal eff ect that can eliminate M. tuberculosis.15 When pulmonary TB patients are resistant to rifampicin, the Table 2. The Mean and Standard Deviation of IL-18 in Pulmonary RR-TB and Pulmonary RS-TB Group N Mean Standard deviation p-value Pulmonary RR-TB 25 1273.53 749.86 0.017 Pulmonary RS-TB 25 787.96 589.28 n = number of samples p < 0,05 = signifi cant Groups IL -1 8 L ev el s Figure 1. IL-18 Levels in Pulmonary RR-TB and Pulmonary RS-TB. This result shows that an increase in IL-18 levels in the blood was found to be signifi cantly higher in pulmonary RR-TB patients compared to pulmonary RS-TB, meaning a higher increase in the infl ammatory process for pulmonary RR-TB patients compared to pulmonary RS-TB patients. This results is also accordance with the result of Wang et al12 study. 120 Copyright © 2020, IJTID, p-ISSN 2085-1103, e-ISSN 2356-0991 Indonesian Journal of Tropical and Infectious Disease, Vol. 8 No. 2 May–August 2020: 116–123 growth of M. tuberculosis will increase and cannot be controlled. Macrophages as the fi rst- line defense will fi ght the bacterial invasion and mediate innate immune responses through the introduction of pathogens and the activation of infl ammatory reactions. Macrophages will polarize to various functional conditions such as M1 which is classically activated and M2 which is alternatively activated. Macrophage polarization into M1 is important for the elimination of intracellular M. tuberculosis. Activation of M1 macrophages through the TLR2 signal pathway can be benefi cial for the host to inhibit growth and the survival of M. tuberculosis.16,17 Increased activation of M1 macrophages in newly infected RR pulmonary TB will produce pro-infl ammatory cytokines which play a role in the mechanism of eliminating M. tuberculosis. This causes the level of pro-infl ammatory cytokines to be higher in RR pulmonary TB serum compared to RS pulmonary TB. The level of pro-infl ammatory cytokines in both RR and RS pulmonary TB is found to be higher compared to the level of anti-infl ammatory cytokines to suppress growth and the survival of M.tuberculosis.12 Increased level of IL-18 in the patients’ serum is also suspected to indicate that there has been a leak of cytokines from the tissues to the circulation. This is supported by various studies which stated that a high concentration of IL-18 are found in TB patients with advanced disease, high fever, and extensive radiographic infi ltrates.7, 18 Increased levels of IL-18 as a pro- inflammatory cytokine in RR pulmonary TB patients are associated with various pathological conditions in the patients themselves. Patients with pulmonary RR-TB with high levels of IL- 18 were also found to have higher ESR and CRP levels compared to pulmonary RS-TB patients and healthy people. ESR and CRP have been used as markers for the diagnosis of pulmonary TB that reflect pathological processes in the patient’s body. Increased CRP and ESR indicate that an acute infl ammatory process has occurred in pulmonary TB patients.12 Higher IL-18 levels found in pulmonary RR-TB patients compared to pulmonary RS-TB patients in this study confi rmed various previous studies which stated that IL-18 levels were signifi cantly increased in patients with severe pulmonary TB. IL-10 Level The highest level of IL-10 in pulmonary RR- TB patients was 465.77 pg/ml, and the lowest was 1.57 pg/ml, while the highest level of IL-10 in pulmonary RS-TB patients was 552.11pg/ml and the lowest level was 1.36 pg/ml. The mean, standard deviation, and p-values of IL-10 level in these two groups are shown in Table 3. The mean of IL-10 level between patients showed no signifi cant diff erences (p>0.05). The diff erences of IL-10 in pulmonary RR-TB and pulmonary RS-TB patients are shown in the boxplot in Figure 2. IL-10 is an anti-infl ammatory cytokine that works by inhibiting the ability of myeloid cells such as macrophages and dendritic cells to activate Th1 cells. Initially, IL-10 is known to be secreted by antigen-stimulated Th2, but it is now known that IL-10 is not only secreted by Th2, but also secreted by a subset of CD4 + T cells, including Th1 and Th17, B cells, neutrophil cells, and macrophages.17 IL-10 is generally thought to modulate the ability of the immune response and allow bacterial elimination without damaging the host tissue, but in some cases the absence of IL-10 makes the immune response more eff ective in eliminating pathogens, but resulting in more damage to the tissue and aff ects the survival of the host.20, 21 The mean level of IL-10 in pulmonary TB patients with RS and RR in this study were 128.81 ± 135.77 pg/ml and 125.15 ± 118.32 pg/ ml respectively. This shows that IL-10 levels in RS were found to be higher than in RR pulmonary Table 3. The Mean and Standard Deviation of IL-10 in Pulmonary RR-TB and Pulmonary RS-TB Group N Mean Standard deviation p-value Pulmonary RR-TB 25 125.15 118.32 0.961 Pulmonary RS-TB 25 128.81 135.77 n = number of samples p > 0,05 = not signifi cant 121Audrey Gracelia Riwu, et al.: Differences of Interleukin-18 and Interleukin-10 Levels Copyright © 2020, IJTID, p-ISSN 2085-1103, e-ISSN 2356-0991 TB, although statistically did not have a signifi cant diff erence (p> 0.05). The results of this study are following a study conducted by Butov et al22 which stated that the mean level of IL-10 in MDR-TB patients’serum before and after 2 months of treatment were found to be lower when compared to non-MDR TB patients and healthy people. This result is in accordance with the result of Lihawa23 and Peñaloza24 study. Lihawa and Yudhawati23 in Dr. Soetomo Hospital showed that descriptively IL-10 levels in MDR-TB patients were found to be lower than non-MDR TB, but statistically no signifi cant diff erences were found. Peñaloza24 was stated that during non-MDR M. tuberculosis infection, IL-10 production is important for host survival, but the role of IL-10 in the immune response of patients with MDR pulmonary TB molecularly has not been found with certainty. This insignifi cant diff erence in IL-10 may indicate a tendency of static state occuring during the acute phase of TB levels IL- 10 due to the role of macrophages which secrete more proinfl ammatory cytokines to protect the host from M. tuberculosis. It is evidenced in this study by the discovery of IL-18 levels that were higher than the IL-10 levels in each group. High levels of IL-10 can only be found in chronic TB infections.25 CONCLUSIONS The level of IL-18 is higher in patients with pulmonary RR-TB compared to pulmonary RS- TB. This circulating level of IL-18 and IL-10 can be used as a marker of infl ammation degrees in pulmonary RR-TB and RS-TB patients. ACKNOWLEDGMENT The author would like to thank the Postgraduate School of Universitas Airlangga and Dr. Soetomo Hospital specifi cally for the Department of Research I L - 1 0 L ev el s Groups Figure 2. IL-10 Levels in Pulmonary RR-TB and Pulmonary RS-TB Patients. The results shows showed no signifi cant diff erences between these two groups. 122 Copyright © 2020, IJTID, p-ISSN 2085-1103, e-ISSN 2356-0991 Indonesian Journal of Tropical and Infectious Disease, Vol. 8 No. 2 May–August 2020: 116–123 and Development which has permitted them to conduct this research in the TB-DOTS/MDR Polyclinic. The author would also like to thank Dr. Soedarsono, dr., Sp.P(K) who has been willing to become a clinical supervisor, to the Research and Development Department of the Clinical Pathology Installation who has helped to carry out the examination using the ELISA method and all of the patients who donated the samples. CONFLICT OF INTEREST There is no confl ict of interest that has to be declared in this study. REFERENCES 1. WHO. Global Tuberculosis Report 2018. Geneva, Switzerland: World Health Organization; 2018. 2. Kemenkes RI. Pedoman Nasional Pengendalian Tuberculosis. Jakarta: Kementrian Kesehatan Republik Indonesia; 2014. 3. Dasilva P, Palomino J. Molecular basis and mechanisms of drug resistance in Mycobacterium tuberculosis: classical and new drugs. J Antimicrob Chemother. 2011; 66(7): 1417–30. doi: 10.1093/jac/dkr173 4. Kurbativa EV, Cavanaugh JS, Shah SN, Wrisht A, Kim HJ, Metchock B. Rifampicin-resistant Mycobacterium tuberculosis susceptibility to isoniazid and other anti- tuberculosis drugs. Int J Tuberc Lung Dis. 2012; 16(3): 355–7. doi: 10.5588/ijtld.11.0542. 5. Wawrocki S, Druszczynska M, Kowalewics M.K, Rudnicka W. Interleukin 18 (IL-18) as a target for immune intervention. Acta Biochim Pol. 2016; 63(1): 59–63. doi: 10.18388/abp.2015_1153. 6. Dinarello C, Novick D, Kim S, Kalplanski G. Interleukin- 18 and IL-18 binding protein Front Immunol. 2013; 4: 289. doi: 10.3389/fi mmu.2013.00289. 7. Han M, Yue J, Lian Y, Zhao Y, Wang H, Liu L. Relationship between single nucleotide polymorphism of interleukin-18 and susceptibility to pulmonary tuberculosis in the Chines Han population. Microbiology and Immunology. 2011: 55: 388–93. doi:10.1111/ j.1348-0421.2011.00332.x 8. Iyer SS, Cheng G. Role of Interleukin 10 Transcriptional Regulation in Infl ammation and Autoimmune Disease. Crit Rev Immunol. 2012; 32(1): 23–63. 9. Ng TH, Britton GJ, Hili EV, Verhagen J, Burton BR, Wrauth DC. Regulation of adaptive immunity; the role of interleukin-10. Front Immunol. 2013; 4; 129. doi:10.3389/fi mmu.2013.00129 10. O’Leary S, O’Sullivan MP, Keane J. IL-10 blocks phagosome maturation in mycobacterium tuberculosis- infected human macrophages. Am J Respir Cell Mol Biol. 2011; 45: 172–80. 11. Abdalla AE, Lambert N, Duan X, Xie J. Interleukin- 10 Family and Tuberculosis: An Old Story Renewed. Int J Biol Sci 2016; 12(6): 710–717. doi:10.7150/ ijbs.13881 12. Wang Y, Chunmei H, Zailang W, Hui K, Weiping X, Hong W. Serum IL-1 and IL-18 Correlate with ESR and CRP in Multi-drug Resistant Tuberculosis Patients. J Biomed Res. 2015; 29(5): 426–28. doi: 10.7555/ JBR.29.20150077 13. Amalia E, Nindatama M.R, Hayati L, Handayani D. (2015). Identifi kasi Mutasi Gen rpob Ser531Leu Mycobacterium tuberculosis yang Berhubungan Dengan Resistensi Rifampsin. Biomed J of Indo, Vol. 1 No.1. 14. Domingo-Gomzales R, Prince O, Cooper A, Khader S. Cytokines and chemokines in Mycobacterium tuberculosis infection. Microbiol Spectr. 2016; 4(5). doi: 10.1128/microbiolspec.TBTB2-0018-2016. 15. Zhang, X., & Guo, J. Advances in the treatment of pulmonary tuberculosis. J Thoracic Dis. 2012; 4(6): 617–623. 16. Lim YJ, Yi MH, Choi JA, Lee J, Han JY, Jo SH, et al. Roles of endoplasmic reticulum stress-mediated apoptosis in M1-polarized macrophages during mycobacterial infections. Sci Rep. 2016; 6:37211DOI: 10.1038/srep37211 17. Wang S, Zhang J, Sui L, Xu H, Piao Q, Qu X, et al. Antibiotics induce polarization of pleural macrophages to M2-like phenotype in patients with tuberculous pleuritis. Sci Rep. 2017; 7(1): 14982. doi: 10.1038/ s41598-017-14808-9. 18. Elarab AE, Garrad H. Serum level of interferon gamma (INF- ), IL-12, and IL-18 in active pulmonary. AAMJ. 2012; 10(3). 19. Redford P, Murray J, O’Garra A. The Role of IL-10 in Immune Regulation during M. tuberculosis Infection. Mucosal Immunol. 2011; 4(3): 261–70. doi: 10.1038/ mi.2011.7. 20. Peñaloza HF, Schultz BM, Nieto PA, Salazar GA, Suazo I, Gonzalez PA, et al. Opposing roles of IL-10 in acute bacterial infection. Cytokine Growth Factor Rev. 2016; 32: 17–30. doi: 10.1016/j.cytogfr.2016.07.003. 21. Ng TH, Britton GJ, Hill EV, Verhagen J, Burton BR, Wraith DC. Regulation of adaptive immunity; the role of interleukin-10. Front Immunol. 2013; 4: 129. doi: 10.3389/fi mmu.2013.00129 22. Butov DO, Mykhalio K, Kuzhko BT. Interleukin-10 Gene Polymorphisms is Associated with Multi-drug resistance Tuberculosis in Ukranian Population. Intl J of Mycobac. 2016; 5: 152–3. 123Audrey Gracelia Riwu, et al.: Differences of Interleukin-18 and Interleukin-10 Levels Copyright © 2020, IJTID, p-ISSN 2085-1103, e-ISSN 2356-0991 23. Lihawa N, Yudhawati R. Hubungan Kadar IL-10 dan Tuberculosis Multi-drug Resistant. Jurnal Respirasi. 2015; 1(2): 41–47 24. Penaloza H, Noguera L, Riedel C, Bueno S. Expanding the Current Knowledge About the Role of Interleukin- 10 to Major Concerning Bacteria. Front Microbiol. 2018; 9: 2047. doi: 10.3389/fmicb.2018.02047 25. O’Garra, Redford P.S, McNab F.W, Bloom C.I, Wilkinson R.J, Berry M. The Immune Response in Tuberculosis. Annurev Immunol. 2013; 31: 475–527.