Tuberculosis in patients infected with the human immunodeficiency virus

A retrospective study of tuberculosis was undertaken among 125 patients infected with human immunodeficiency virus (HIV) who attended our regional infectious disease unit between 1986 and 1989. Nine TB-positive patients (five English, three Africans, one Indian) were identified. In three patients who presented with pyrexia of unknown origin and no objective evidence of any organ involvement, the diagnosis of TB was established from examination of sputum induced by nebulized hypertonic saline. Four other patients had extrapulmonary disease while another two had only pulmonary manifestations of TB. Chest radiographs from five patients were normal, while the other four showed cavities with consolidation, pleural effusion, miliary opacities and hilar enlargement, respectively. All but two mycobacterial isolates were fully sensitive to standard first-line chemotherapeutic drugs. Response to treatment was rapid and only complicated in one patient. There were no relapses following treatment without maintenance therapy after a mean follow-up of 22.2 months (range 9-48). Three patients died, of causes unrelated to TB. Tuberculosis may occur at any stage of HIV disease and is an important cause of fever in HIV-infected British patients, even when chest radiographs are normal and previous BCG vaccination has been performed.     

Tuberculosis in HIV/AIDS patients

The recent literatures and guidelines of TB/HIV were reviewed. The Japanese research survey revealed that 0.37% of active TB patients were estimated to be HIV-positive. Over 60% of the HIV-infected patients with TB disease were diagnosed as having TB and being HIV-positive almost simultaneously. All HIV-infected patients with diagnosed active TB should be started on TB treatment immediately and active TB patients but not yet on antiretroviral therapy (ART) should be treated with ART within 2 to 8 weeks of starting TB treatment depending on CD4 status. All HIV-infected persons are recommended to receive the test for LTBI and also active TB disease could be prevented by application of WHO three 'I's.     

Feasibility of an Emergency Department-based Tuberculosis Counseling and Screening Program

OBJECTIVE: To assess the feasibility and effectiveness of an ED-based tuberculosis (TB) screening program. METHODS: A TB screening program of adult ED patients was conducted at a university hospital ED with 46,000 annual visits that serves a poor urban community. Patients were screened on weekdays during business hours. ED patients were counseled about the disease and the screening procedure and, after consent, purified protein derivative (PPD) tests were placed. Patients returned in 48-72 hours for reaction reading and post-test counseling. PPD-positive patients received a physical examination, chest x-ray, and HIV testing and were referred to a city TB clinic for possible treatment. RESULTS: Overall, 873 patients were counseled, 630 were eligible for screening, and 374 (59.4%) consented to PPD testing. Of the 203 (54.1%) who returned, 32 (15.8%) were PPD-positive. No active case was detected, but 26 patients were referred to the health department. Eighteen kept their appointments and all 13 who were started on therapy completed treatment. Targeted screening of groups aged 55 years or more, nonwhite groups, and those with other high-risk factors would detect 84% of PPD-positive cases while testing only 48% of eligible patients. CONCLUSION: An ED-based TB screening program is feasible and can identify many patients requiring treatment. Targeted screening of high-risk groups could reduce the program cost, but would miss some cases.     

Tuberculosis, HIV and the developing world

This article reviews the immunology, genetics, epidemiology and treatment of two of the most important infectious diseases in the world, HIV and tuberculosis (TB). The pandemic of TB has been greatly magnified by the advent of the HIV epidemic. In the developing world, probably 50% of HIV seropositive individuals are co-infected with TB. The TB epidemic has expanded both because of increased susceptibility of patients to new tuberculous infection and also because of the greater chance of a primary complex leading to disseminated disease. The evidence that TB has had any effect on the HIV epidemic is less clear in the developed world with effective antiretroviral therapy. In resource-poor countries, many HIV infected individuals die prematurely of TB. Both organisms infect immunologically competent cells, and the control of infection in both has a large genetic component. The complex immunological response and process of cytokine release has a marked impact on both control of disease and the pathological effects of infection. Treatment of TB was associated with the development of resistance until the need for combination chemotherapy was recognised. It was then realised that one of the major factors making treatment of TB difficult was poor long-term adherence. Exactly the same sequence of events in terms of our understanding of the treatment of HIV infection has occurred more recently. These two infections undoubtedly present the most serious challenge to public health across the world, and are likely to be controlled only by a global mobilisation of resources not seen since the end of the last European war.     

Compliance with the treatment by patients with the co-infection HIV/tuberculosis: integrative literature review

This is an integrative review whose objective was to evaluate the evidences available in the literature about the factors associated to the compliance with the treatment by patients with the co-infection HIV/TB. Articles published in the period from 2002 to 2008, in the databases LILACS and MEDLINE were analyzed. The material was categorized according to the year of publication, periodical, study location and factors related to the compliance. The final sample included eight articles. The factors found, associated to the compliance with the treatment of the co-infection HIV/TB, related to: the individual and his lifestyle (previous TB treatment, fear of stigma and discrimination, use of chemical substances, depression, social support); the disease and the medication (type of medication regime, use of other medication, adverse effects, difficulty to diagnose TB in these patients); and the health services (operational problems to follow up the treatment, training of the professionals, supervision, different locations to treat TB and HIV).     

Active tuberculosis in the medical intensive care unit: a 15-year retrospective analysis

Of approximately 6000 admissions to the Henry Ford Hospital medical ICU between October 1969 and September 1984, 61 (1%) had active tuberculosis (TB). Forty-three (70%) of these 61 had acute respiratory failure (ARF). TB was considered to be the sole cause of ARF in 12 and contributory in 31. Eighteen patients with TB but without ARF were admitted for treatment of other critical illnesses. Alcoholism was present in 31 (51%) of the TB patients. Only one of 12 whose ARF was caused primarily by TB had a history of known TB at the time of admission. Important factors contributing to ARF in TB patients included Gram-negative pneumonia and/or sepsis, chronic obstructive pulmonary disease, prior TB with anti-TB medication noncompliance, and malignancy. Six patients were not suspected of having TB when admitted to the medical ICU; three patients who had not been treated for TB were found to have TB on autopsy. The inhospital mortality rate for all patients with TB requiring intensive care was 67%, but was 81% in those with ARF.     

Testing for HIV among patients with tuberculosis in Montreal.

OBJECTIVE: To determine the rate of HIV testing among patients with tuberculosis (TB) in Montreal, and to identify patient characteristics associated with physician screening patterns. Knowledge of local patterns of HIV testing among patients with TB could be used to facilitate the development of strategies to improve compliance with recommendations that all patients with TB be screened for HIV. DESIGN: Retrospective chart review. PATIENTS: All patients with TB reported to the Montreal Public Health Unit from 1992 to 1994 (ages 19 to 50) and from 1992 to 1995 (ages 18 and under) and for whom a chart could be reviewed. OUTCOME MEASURES: Patients with TB screened versus not screened for HIV infection, analyzed to determine which variables independently predict the likelihood of screening for HIV infection. RESULTS: Of the 376 patients with TB for whom data were available, 192 (51%) were screened for HIV. Of those, 33 (17%) had been tested before having received the diagnosis of TB. Multivariate analysis revealed that patients with TB who were male, aged 30 to 39, had a positive sputum smear, displayed at least 1 clinical symptom, received the TB diagnosis from a microbiologist or infectious disease specialist, or reported 1 or more HIV risk factors were more likely to be screened for HIV. CONCLUSIONS: HIV screening of patients with TB is selective, depending on both patient and physician characteristics. Physicians' awareness of recommendations needs to be increased to improve the diagnosis and treatment of TB/HIV co-infection.     

Radiographic presentation of pulmonary tuberculosis in severely immunosuppressed HIV-seropositive patients

Although the presence of typical postprimary or “reactivation” pattern tuberculosis (TB) on chest radiograph (CXR) strongly suggests TB infection in adults, the sensitivity of this finding, particularly in severely immunosuppressed human immunodeficiency virus (HIV) patients, is unclear. To investigate this issue, HIV status, CD4 counts, and CXR findings of all adult patients with culture-proven TB admitted to a tertiary-care hospital over a 2-year period were retrospectively studied. CXRs were classified as typical for postprimary TB if they showed upper lobe opacities with or without cavitation. No attempt was made to correlate the actual clinical phase of TB infection (primary versus postprimary) with CXR patterns, largely because differentiating primary from postprimary TB in HIV patients is difficult due to high anergy rates and inability to skin-test-convert. Of 46 patients who had chest radiographs and medical records documenting HIV status available for review, 23 were HIV-seropositive and 23 were HIV-seronegative. Of 22 HIV-seropositive patients whose CD4 counts were available, 18 (82%) had CD4 counts of <200 cells/μL. Only 2 of these 18 (11%) had CXRs showing a typical postprimary TB pattern, whereas all 4 (100%) patients with CD4 counts of 〉200 cells/μL and 18 of 23 (78%) non-HIV patients had CXRs typical for postprimary TB (P < .005). It was concluded that HIV-seropositive patients with TB and CD4 counts of <200 cells/μL frequently present with chest radiographs atypical for postprimary TB, including normal CXRs. Typical postprimary TB CXR findings are not sensitive for diagnosing pulmonary TB in this population.     

Management of advanced HIV disease in patients with tuberculosis or hepatitis co-infection

Advanced human immunodeficiency virus (HIV) disease can be defined as a cluster of differentiation 4 (CD4) count <50 cells/mm³ or the presence of an acquired immunodeficiency syndrome (AIDS)‐defining illness. In the UK and Ireland, the number of patients who present with advanced HIV disease is increasing, with 301/977 (31%) of patients presenting late (<200 CD4 cells/mm³). Many patients who present with advanced HIV disease will have comorbid conditions, such as hepatitis B or C or tuberculosis (TB), which complicates the choice of therapy. This article reviews the evidence and some clinical scenarios for specific patient groups who may present with advanced HIV disease: those with comorbid TB, hepatitis B or hepatitis C. The aim is to offer practical advice on therapeutic options for treatment‐naïve patients who present with advanced HIV disease on the basis of available clinical evidence.     

青海省结核病患者治疗结局影响因素分析及贝叶斯网络模型研究

  目的  分析2011 — 2019年青海省登记报告的结核病患者治疗结局的影响因素,并通过构建贝叶斯网络模型进行因果效应推断和条件概率分析。  方法  通过全国结核病管理系统导出2011 — 2019年青海省登记报告的结核病例信息,描述其治疗结局现状,并利用多因素logistic回归分析结核病患者治疗结局的影响因素,将具有统计学意义的影响因素纳入贝叶斯网络模型中进行因果关联和条件概率推断。  结果  2011 — 2019年青海省结核病患者治疗成功率为88.86%。 多因素logistic回归分析结果显示,患者来源中的因症就诊、转诊和追踪以及诊断分型是影响结核病患者治疗结局的保护因素,而高年龄组（≥55岁）、农牧民、患者来源中的健康检查及其他接触者检查、重症、复治和非全程管理督导是危险因素。 通过构建贝叶斯网络模型可以得出,患者来源、是否重症和管理方式与治疗结局存在因果关联,当因症就诊的非重症结核病患者被全程管理督导时,其治疗成功率最高（95.63%）,出现不良结局概率最低（4.37%）。  结论  年龄、职业、患者来源、诊断分型、重症、治疗分类和管理方式是结核病患者治疗结局的影响因素,因症就诊的非重症结核病患者被全程管理督导时治疗成功率最高。     

Simultaneous occurrence of Hodgkin disease and tuberculosis: report of three cases

Tuberculosis (TB) has been described in association with malignancies including Hodgkin disease (HD). We report three cases of simultaneous occurrence of TB and HD. In two of these cases clinical symptoms improved after TB treatment was instituted and before HD was diagnosed. Fever recurrence in one case and persistence of mediastinal lymphadenopathy in the other, however, prompted consideration of an additional diagnosis. Interestingly, in one these two patients, both TB and HD diagnosis were obtained from the same lymph node. Since both diseases share many symptoms and signs, physicians faced with initial therapeutic failure when caring for HD and TB patients should be aware of the possibility of the simultaneous occurrence of both diseases.     

浙江省艾滋病病毒感染者和艾滋病患者中结核病筛查情况分析

目的通过掌握艾滋病病毒感染者和艾滋病（HIV/AIDS）患者中结核病的患病情况及发病趋势,以便对结核病和艾滋病双重感染者开展防治。方法对登记在册的HIV/AIDS人群进行症状询问、胸部拍片、痰涂片。结果通过筛查577例HIV/AIDS患者,发现结核病33例, 结核病患病率为5.72%;活动性肺结核31例,患病率为5.37%;痰涂片阳性4例,涂阳患病率为0.69%。其中HIV感染者检出率为3.36%,AIDS患者检出率为12.50%,差异有统计学意义 (I/Isup2/sup=16.36,IP/I＜0.01)。结论HIV/AIDS人群是感染结核病的高危人群,应定期进行结核病筛查,做到早期发现,早期治疗。     

Tuberculosis and HIV infection. How to safely treat both disorders concurrently

Progress has been made in screening, early recognition, prevention, and treatment of TB, but its coexistence with HIV infection continues to present a challenge. Healthcare professionals should be familiar with guidelines for treating HIV-infected patients with TB while concurrently administering highly active antiretroviral therapy. Primary care physicians are encouraged to consult specialists who are familiar with treatment of patients with such coexisting disease. Whenever feasible, directly observed therapy should be instituted in all cases of TB to promote compliance and reduce the incidence of drug resistance and treatment failure.     

No implication of HIV coinfection on the plasma exposure to rifampicin,pyrazinamide, and ethambutol in tuberculosis patients

There are contrasting findings regarding the effect of HIV on the pharmacokinetics of first‐line anti‐tubercular drugs (FLATDs) due to a lack of prospective controlled clinical studies, including patients with tuberculosis (TB) and patients with TB living with HIV. This study aims to assess the effect of HIV coinfection and antiviral therapy on the plasma exposure to FLATDs in patients with TB. HIV negative (TB‐HIV− group; n = 15) and HIV positive (TB‐HIV+ group; n = 18) adult patients with TB were enrolled during the second month of FLATDs treatment. All TB‐HIV+ patients were on treatment with lamivudine, tenofovir (or zidovudine), and raltegravir (or efavirenz). Serial blood sampling was collected over 24 h and FLATDs pharmacokinetic parameters were evaluated using noncompartmental methods. In the TB‐HIV+ patients, dose‐normalized plasma exposure area under the curve from zero to 24 h (nAUC_0–24; geometric mean and 95% confidence interval [CI]) values at steady‐state to rifampicin, pyrazinamide, and ethambutol were 18.38 (95% CI 13.74–24.59), 238.21 (95% CI 191.09–296.95), and 18.33 (95% CI 14.56–23.09) µg∙h/ml, respectively. Similar plasma exposure was found in the TB‐HIV− patients. The geometric mean and 90% CI of the ratios between TB‐HIV− and TB‐HIV+ groups suggest no significant pharmacokinetic interaction between the selected antivirals and FLATDs. Likewise, HIV coinfection itself does not appear to have any effect on the plasma exposure to FLATDs.

Study Highlights

• WHAT IS THE CURRENT KNOWLEDGE ON THE TOPIC?

First‐line anti‐tubercular drugs (FLATDs) plasma exposure is an important variable of tuberculosis (TB) outcome; however, there are contrasting findings regarding the effect of HIV on the pharmacokinetics of FLATDs due to a lack of prospective controlled clinical studies, including HIV positive and HIV negative patients with TB.

• WHAT QUESTION DID THIS STUDY ADDRESS?

This study evaluates the effect of HIV coinfection on the pharmacokinetics of rifampicin, pyrazinamide, and ethambutol in patients who are on stable therapy in the second month of FLATDs treatment.

• WHAT DOES THIS STUDY ADD TO OUR KNOWLEDGE?

This study shows no evidence that the pharmacokinetics of rifampicin, pyrazinamide, and ethambutol in patients with TB are affected by HIV coinfection or by any of the standard of care HIV comedications allowed in the study (lamivudine, zidovudine, tenofovir, efavirenz, or raltegravir).

• HOW MIGHT THIS CHANGE CLINICAL PHARMACOLOGY OR TRANSLATIONAL SCIENCE?

HIV coinfection does not require dose adjustment of rifampicin, pyrazinamide, and ethambutol in patients with TB.     

我院对TB／HIV双重感染患者的综合管理方法

目的探讨TB／HIV双重感染患者在结核门诊治疗的综合管理方法。方法确诊病例以城区为单位划片管理,督导护士负责患者门诊治疗全程督导：执行治疗方案与用药及消毒隔离指导、培训家庭督导员、访视等综合管理工作。结果16例痰涂片阳性TB／HIV双重感染患者肺结核治愈15例,1例死亡。40例痰涂片阴性TB／HIV双重感染患者,其中22例完成化疗疗程,肺结核治愈,定期门诊复查或继续接受抗病毒治疗。56例患者在门诊接受综合管理中,未发生护理差错和护患纠纷,对护理服务表示满意。结论有效的综合管理可使TB／HIV双蕈感染患者在结核门诊完成化疗疗程。     

HIV/AIDS患者合并活动性结核病的诊断及方法探讨

目的 在HIV/AIDS患者中筛查活动性结核(TB),并对TB/HIV双重感染患者的活动性rrB诊断方法进行探讨.方法 2006年8月至2007年3月调查南宁市和柳州市4家AIDS定点诊疗机构的660例HIV/AIDS患者,对CD+4T淋巴细胞计数≤350/mm3或至少有TB可疑症状之一的HIV/AIDS患者进行胸部x线平片、痰抗酸染色涂片和液体快速培养检查.结果 CD+4T淋巴细胞计数≤200个/mm3的患者占76.1%(502/660).HIV/AIDS患者合并活动性结核病的比例为22.9%(151/660),其中肺结核占74.8%(113/151),1/3的患者有肺外累及,肺外TB以淋巴TB为主,占68.1%.在痰涂片和胸部X线平片均不支持活动性TB的患者中培养阳性的占20.1%(53/264).在培养阳性的病例中38.5%(35/91)是非结核分枝杆菌感染.结论 本研究HIV/AIDS患者中合并活动性结核病的比例为22.8%.痰的快速培养在HIV/AIDS患者中诊断结核病中起至关重要的作用.HIV/MDS患者合并非结核分枝杆菌以及肺外TB比例不容忽视.     

Frontal assault on tuberculosis. Interview by Eileen Fursland

Nurses working with people who have TB in London battle to reduce the stigma attached to the disease. For many patients, TB is just one of many problems they have to contend with. People living in shared accommodation can face homelessness as a result of their infection. In some countries TB is associated with HIV, increasing the stigma patients face. Some patients are given incentives to encourage concordance with treatment.     

Early antiviral treatment of hepatitis C virus recurrence after liver transplantation in HIV-infected patients

OBJECTIVE: To investigate the efficacy of early antiviral treatment for hepatitis C virus (HCV) recurrence in HIV/HCV-coinfected patients undergoing liver transplantation for end-stage liver disease. METHODS: Open prospective trial of early treatment of HCV recurrence in consecutive HIV/HCV-coinfected patients transplanted at a tertiary hospital in Barcelona between 2002 and 2004. All patients had indication for liver transplantation, no previous CDC class C HIV-associated opportunistic events, a CD4+ T-cell count >100cells/microl, and undetectable plasma HIV RNA on highly active antiretroviral therapy. Treatment with pegylated interferon-alpha2b (1.5 microg/kg/week) and ribavirin (800-1000 mg/day) was given for 24 to 48 weeks, as soon as HCV recurrence was histologically documented. RESULTS: Of six patients who underwent transplant, five patients surviving the early post-transplantation period developed HCV recurrence, presenting as severe cholestatic hepatitis in three, and were started on antiviral treatment a median of 12 weeks (range: 5-31) after transplantation. After a median follow-up of 24 months all treated patients were alive. Biochemical response was achieved in all patients, although only one achieved a sustained virological response. Mild rejection before HCV recurrence occurred in two cases. Treatment was well tolerated with no episodes of rejection or mitochondrial toxicity. No patient required modification of the antiretroviral regimen. Liver biopsies performed in patients without virological response, 12-34 months after transplantation, showed cirrhosis in two and moderate chronic active hepatitis in the remainder. CONCLUSIONS: Despite early antiviral treatment, severe HCV recurrence after liver transplantation may compromise long-term survival in HIV-infected patients. Improved treatment strategies for these patients are urgently required.     

Chronic pericardial disease in patients with rheumatoid arthritis: a longitudinal study

We have reviewed the clinical and investigative findings in 13 patients with chronic pericardial disease and seropositive rheumatoid arthritis. In eleven cases the diagnosis was made on clinical grounds, while the diagnosis was confirmed only at post-mortem in two patients. Pleural effusions were present in seven patients, while pulsus paradoxus was found in only one case. Echocardiograms were undertaken in ten patients and all showed evidence of pericardial effusions, which were usually small and sited posteriorly. A delayed ventricular filling pattern indicating abnormal ventricular relaxation was seen in two patients with cardiac tamponade. The surviving 11 patients were reviewed a median of three years after diagnosis of their pericardial disease. Pericardectomy had been performed in six, all of whom were asymptomatic and had a normal chest radiograph. Steroids alone had been given to the other five, and three of these remained dyspnoeic with cardiomegaly. The clinical features distinguishing chronic pericardial disease from other causes of right heart failure in rheumatoid arthritis patients are subtle. As management is fundamentally different, serious consideration should be given to the diagnosis of chronic pericardial disease in any patient with rheumatoid arthritis who presents with right-sided heart failure.     

The Treatment of Cushing's Disease by Trans-sphenoidal Hypophysectomy

Thirteen patients aged 24 to 65 with Cushing's disease havebeen treated by tranfssphenoidal hypophysectomy. There was oneincident of meningitis and one late death from myocarditis.No radiotherapy was given. In 12 patients pituitary histologyshowed Crooke's changes and an adenoma was present in seven.On review of the 12 survivors two to 11 years later, 11 arein complete remission. One patient still showed some clinicalfeatures of Cushing's syndrome but steroid levels were normal.In five of the seven premenopausal women normal menstruationhas returned and pregnancy has occurred in three. In four patientsreplacement hormone therapy is no longer required and a furtherfour take only partial treatment. We conclude that transsphenoidalhypophysectomy is an effective treatment for Cushing's disease.