Tuberculosis treatment reshapes ferroptosis-related blood markers in small Iraqi study

Adults with newly diagnosed pulmonary tuberculosis show a distinctive circulating pattern of ferroptosis-related and inflammatory biomarkers that shifts markedly over the six months of standard treatment, according to a prospective longitudinal case-control study conducted at a chest clinic in Wasit Province, Iraq. The findings, published in Molecular Biology Reports, suggest that markers linked to the iron-dependent cell death pathway known as ferroptosis track the course of active disease, though the authors caution that the measurements cannot by themselves establish that ferroptotic cell death actually occurs.

The study enrolled 30 adults with newly diagnosed pulmonary tuberculosis and 30 healthy controls. Patients were assessed at three time points: before treatment began, after two months of therapy, and at completion of the six-month regimen. Controls were assessed once. The researchers measured whole-leukocyte mRNA expression of two genes central to ferroptosis biology, GPX4 and ACSL4, alongside serum concentrations of 4-hydroxynonenal (4-HNE), soluble ST2 (sST2), interleukin-33 (IL-33), ferritin, iron and lactate dehydrogenase (LDH). All comparisons were adjusted for multiple testing using the Holm correction.

At baseline, patients differed from controls on every marker in the panel. They had lower GPX4 expression and lower serum iron, but higher ACSL4 expression and higher levels of 4-HNE, sST2, IL-33, ferritin and LDH, with all differences reaching p < 0.0001 and remaining significant after covariate adjustment.

During treatment, the profile moved in the opposite direction. GPX4 expression and serum iron rose over the six months, while the other six markers fell. By the end of therapy, however, full normalisation had not occurred for every analyte. ACSL4 and LDH remained significantly different from controls even after correction for multiple comparisons. sST2 and serum iron differed from controls only in unadjusted comparisons, and no difference was detected for GPX4, 4-HNE, IL-33 or ferritin.

The researchers also examined how well individual markers separated patients from controls, reporting apparent areas under the curve of 0.997 (95% CI 0.982–1.000) for GPX4, 0.995 (95% CI 0.977–1.000) for ACSL4 and 1.000 (95% CI 1.000–1.000) for LDH. These values are described as derivation-sample estimates, meaning they were calculated within the same cohort used to build the analysis and are likely to be optimistic relative to performance in entirely new populations.

The authors conclude that active pulmonary tuberculosis was associated with a treatment-responsive circulating profile consistent with altered ferroptosis-related biology. They are explicit about the limits of that conclusion. Circulating markers cannot establish that ferroptotic cell death is taking place, identify which cells are dying that way, demonstrate that the pattern is specific to tuberculosis rather than other inflammatory conditions, or show that the measurements are useful for monitoring treatment in clinical practice.

Several constraints follow from the study design. The cohort was small, with 30 patients and 30 controls recruited at a single clinic, and the control group was assessed only once, which limits what can be said about within-person variability in healthy people. The authors state that validation in larger cohorts with clinically relevant disease controls is required before any broader conclusions can be drawn. Until such studies are done, the results stand as an observational characterisation of how a defined biomarker panel behaves during tuberculosis treatment, not as evidence of a causal mechanism or a validated clinical test.

The work adds to a growing interest in ferroptosis as a possible contributor to macrophage injury in tuberculosis, a hypothesis the authors note motivated the study. The current data are consistent with such biology but do not test it directly at the cellular level, leaving the mechanistic question open for future research.

Subject of Research: Longitudinal changes in ferroptosis-related and inflammatory biomarkers during pulmonary tuberculosis treatment

Article Title: Longitudinal changes in ferroptosis-related and inflammatory biomarkers during treatment of pulmonary tuberculosis: a prospective longitudinal case-control study

Article References: Al-razaq, D. A. A.-K. A., Mohammed, H. Q., & Mohammed, H. A. (2026). Longitudinal changes in ferroptosis-related and inflammatory biomarkers during treatment of pulmonary tuberculosis: a prospective longitudinal case-control study. Molecular Biology Reports, 53(1), 1834. https://doi.org/10.1007/s11033-026-13078-x

Image Credits: AI Generated

DOI: 10.1007/s11033-026-13078-x

Keywords: tuberculosis, ferroptosis, biomarkers, GPX4, ACSL4, LDH, 4-HNE, sST2, IL-33, longitudinal study, case-control, Iraq