Pulmonary tuberculosis in Kigali, Rwanda. Impact of human immunodeficiency virus infection on clinical and radiographic presentation

Tuberkulose im Erwachsenenalter

Die Tuberkulose ist in Deutschland eine seltene, überwiegend gut behandelbare Erkrankung. Weltweit ist sie eine der häufigsten Infektionserkrankungen mit ca. 10 Millionen Neuerkrankungen/Jahr. Auch bei einer niedrigen Inzidenz in Deutschland bleibt Tuberkulose insbesondere aufgrund der internationalen Entwicklungen und Migrationsbewegungen eine wichtige Differenzialdiagnose. In Deutschland besteht, aufgrund der niedrigen Prävalenz der Erkrankung und der damit verbundenen abnehmenden klinischen Erfahrung, ein Informationsbedarf zu allen Aspekten der Tuberkulose und ihrer Kontrolle. Diese Leitlinie umfasst die mikrobiologische Diagnostik, die Grundprinzipien der Standardtherapie, die Behandlung verschiedener Organmanifestationen, den Umgang mit typischen unerwünschten Arzneimittelwirkungen, die Besonderheiten in der Diagnostik und Therapie resistenter Tuberkulose sowie die Behandlung bei TB-HIV-Koinfektion. Sie geht darüber hinaus auf Versorgungsaspekte und gesetzliche Regelungen wie auch auf die Diagnosestellung und präventive Therapie einer latenten tuberkulösen Infektion ein. Es wird ausgeführt, wann es der Behandlung durch spezialisierte Zentren bedarf.

Die Aktualisierung der S2k-Leitlinie „Tuberkulose im Erwachsenenalter“ soll allen in der Tuberkuloseversorgung Tätigen als Richtschnur für die Prävention, die Diagnose und die Therapie der Tuberkulose dienen und helfen, den heutigen Herausforderungen im Umgang mit Tuberkulose in Deutschland gewachsen zu sein.

Post tuberculosis chronic lung disease in tuberculosis HIV coinfected and non-HIV individuals in Sub-Saharan Africa: A systematic review and meta-analysis

Background

Post tuberculosis (TB) sequelae are faced by many individuals who survive TB. The most common of all is post-TB chronic lung disease (CLD) and pulmonary impairment. We reviewed studies that estimated the prevalence of post-TB CLD in patients with TB only and those with TB-HIV coinfection.

Methods

Searched Google scholar, PubMed, African journals online, Embase, and Cochrane Central Register of Clinical Trials from the year 2000 to 01 March 2022 for all designs of studies that examined the impact of post on lung impairment or damage. The protocol was registered in PROSPERO, ID: chronic respiratory disease 42022304628.

Results

Three hundred and thirty-six studies were identified and five studies were identified through other sources, four were finally in the meta-analysis with a total of 4382 enrolled participants. All the studies had a low risk of bias; The prevalence of CLD between the TB HIV coinfection and those with TB only was of no statistical significance between the three of the four studies - new statement: the prevalence of CLD in the TB-HIV coinfected group when compared to the group of participants with TB only was not statistically significant in the study. This was seen in three of the four studies. One study was in favor of the high prevalence of CLD in HIV coinfection participants (relative risk [RR] = 0.75 [0.61-0.89] with 95% confidence interval [0.61-0.89]).

Conclusions

Post-TB lung disease is still a burden that needs advocation and an increase of awareness is necessary from the health-care level to the communities and societies, especially in regions of high prevalence. Development of guidelines for health-care workers to aid the management of individuals, multi-disciplinary advocacy is necessary for those whom prevention is not too late.

Trends in the Epidemiology and Outcomes of Pneumocystis Pneumonia among Human Immunodeficiency Virus (HIV) Hospitalizations

Introduction: Pneumocystis Pneumonia (PCP) is a common opportunistic infection among people living with the human immunodeficiency virus (HIV). This study’s objective was to assess temporal trends in PCP epidemiology among hospitalized patients with HIV/AIDS in the US and to compare data for hospitalizations with HIV with PCP to those without PCP. Methods: The national inpatient sample (NIS) data were analyzed from 2002−2014. The discharge coding identified hospitalized patients with HIV or AIDS and with or without PCP. Results: We identified 3,011,725 hospitalizations with HIV/AIDS during the study period; PCP was present in 5% of the patients with a diagnosis of HIV. The rates of PCP progressively declined from 6.7% in 2002 to 3.5 % in 2014 (p < 0.001). Overall mortality in patients with HIV was 3.3% and was significantly higher in those with PCP than without PCP (9.9% vs. 2.9%; p < 0.001). After adjusting for demographics and other comorbidities, PCP had higher odds of hospital mortality 3.082 (OR 3.082; 95% CI, 3.007 to 3.159; p < 0.001). Conclusion: From 2002 to 2014, the rate of PCP in HIV patients has decreased significantly in the United States but is associated with substantially higher mortality.

Utility of urine as a clinical specimen for the diagnosis of pulmonary tuberculosis in people living with HIV in Addis Ababa, Ethiopia

Background

Tuberculosis is a common cause of mortality and morbidity among people living with HIV/AIDS. Despite the increased prognosis of tuberculosis among HIV infected patients, diagnosis of pulmonary tuberculosis (PTB) smear microscopy has a low sensitivity due to low bacterial load in a sputum specimen of HIV patients. Having alternative specimens for increasing detection of Mycobacterium tuberculosis (Mtb) is very important.

Objective

The aim of this study was to evaluate the efficacy of urine as clinical specimen for the diagnosis of pulmonary tuberculosis in people living with HIV.

Method

A total of 117 HIV-seropositive individuals from three public health facilities in Addis Ababa, Ethiopia were enrolled consecutively from December 2013 to July 2014. A total of 117 paired morning sputum and urine samples were simultaneously collected from anti-retroviral therapy (ART) naïve PTB suspected individuals living with HIV. Both sputum and urine samples were processed for culture using Lowenstein-Jensen medium, and the left was subjected to PCR using RD9 primers. Chi-square test and kappa value were used to compare different methods used.

Result

Out of 117 suspected PTB HIV-infected people, sputum culture alone detected more mycobacterial isolates 33 (28.2%) than the urine specimen alone 17 (14.5%). Of the 33 patients positive for sputum culture, 13 patients were observed as a urine culture positive. Of the 84 individuals negative for mycobacterial by sputum culture, four (4.8%) were urine culture positive and thus, the sensitivity, and the agreement between urine culture as compare to sputum culture were 39.4% and 0.49, respectively. On the other hand, the sensitivity of RD9-based PCR directly on urine was 72.7% by considering sputum culture as a reference standard. Moreover, RD9-based PCR directly on sputum detected 9 (7.7%) individuals who were sputum culture negative for M. Tuberculosis. The detection rate of M. tuberculosis from urine in patients those who couldn't produce sputum were 9(34.6%).

Conclusion

PCR and culture examination of urine samples also can improve the detection rate of M. tuberculosis in PTB suspected HIV positive individuals.

Tuberculosis Associated with HIV Infection

Tuberculosis (TB) has recently surpassed HIV as the primary infectious disease killer worldwide, but the two diseases continue to display lethal synergy. The burden of TB is disproportionately borne by people living with HIV, particularly where HIV and poverty coexist. The impact of these diseases on one another is bidirectional, with HIV increasing risk of TB infection and disease progression and TB slowing CD4 recovery and increasing progression to AIDS and death among the HIV infected. Both antiretroviral therapy (ART) and latent TB infection (LTBI) treatment mitigate the impact of coinfection, and ART is now recommended for HIV-infected patients independent of CD4 count. LTBI screening should be performed for all HIV-positive people at the time of diagnosis, when their CD4 count rises above 200, and yearly if there is repeated exposure. Tuberculin skin tests (TSTs) may perform better with serial testing than interferon gamma release assays (IGRAs). Any patient with HIV and a TST induration of ≥5 mm should be evaluated for active TB disease and treated for LTBI if active disease is ruled out. Because HIV impairs multiple aspects of immune function, progressive HIV is associated with lower rates of cavitary pulmonary TB and higher rates of disseminated and extrapulmonary disease, so a high index of suspicion is important, and sputum should be obtained for evaluation even if chest radiographs are negative. TB diagnosis is similar in patients with and without TB, relying on smear, culture, and nucleic acid amplification tests, which are the initial tests of choice. TSTs and IGRAs should not be used in the evaluation of active TB disease since these tests are often negative with active disease. Though not always performed in resource-limited settings, drug susceptibility testing should be performed on all TB isolates from HIV-positive patients. Urine lipoarabinomannan testing may also be helpful in HIV-positive patients with disseminated disease. Treatment of TB in HIV-infected patients is similar to that of TB in HIV-negative patients except that daily therapy is required for all coinfected patients, vitamin B6 supplementation should be given to all coinfected patients receiving isoniazid to reduce peripheral neuropathy, and specific attention needs to be paid to drug-drug interactions between rifamycins and many classes of antiretrovirals. In patients requiring ART that contains ritonavir or cobicistat, this can be managed by the use of rifabutin at 150 mg daily in place of rifampin. For newly diagnosed coinfected patients, mortality is lower if treatment is provided in parallel, rather than serially, with treatment initiation within 2 weeks preferred for those with CD4 counts of <50 and within 8 to 12 weeks for those with higher CD4 counts. When TB immune reconstitution inflammatory syndrome occurs, patients can often be treated symptomatically with nonsteroidal anti-inflammatory drugs, but a minority will benefit from steroids. Generally, patients who do not have space-occupying lesions such as occurs in TB meningitis do not require cessation of therapy.

Detection of Mycobacterium tuberculosis from the stool of HIV sero-positive individuals suspected of pulmonary tuberculosis

BACKGROUND

The impact of tuberculosis (TB) is exacerbated in Africa because of the human immunodeficiency virus (HIV) pandemic. Pulmonary tuberculosis (PTB) diagnosis is difficult in HIV-infected patients and negative sputum results are more common which leads to diagnostic delay and increases morbidity and mortality. Extra-pulmonary samples such as stool may be easier to obtain and our approach may therefore significantly improve PTB detection in people living with HIV.

OBJECTIVE

To detect Mycobacterium tuberculosis from the stool of HIV sero-positive individuals suspected of pulmonary TB.

METHOD

A total of 117 HIV-infected individuals from three public health facilities in Addis Ababa, Ethiopia were enrolled consecutively in the study. Paired morning sputum and stool samples were simultaneously collected from anti-retroviral therapy (ART) naïve individuals living with HIV and suspected for PTB. The diagnostic accuracy of the smear microscopy, culture and region of difference (RD)9-based polymerase chain reaction (PCR) in stool was compared with the accuracy of sputum testing. Chi-square test and kappa value were used to compare different method used.

RESULTS

Sputum culture positivity for mycobacteria was confirmed in 33(28.2%) of the study subjects. Of 33 individuals positive for sputa culture, 10 individuals were observed to be stools culture positive. Of the 84 individuals negative for mycobacteria by sputum culture, three (3.6%) were stool culture positive and thus, the sensitivity and agreement between stool culture as compare to sputum culture were 30.3% and 0.33, respectively. Of 117 individuals, 11(9.4%) were sputum smear positive and of 11 sputum smear positive three were also stool smear positive. While of the 106 sputum smear negative individuals', only one was stool smear positive resulting in 12.1% sensitivity and 0.18 agreements against sputum culture. On the other hand, the sensitivity of RD9-based PCR directly on stool was 69.7% by considering sputum culture as a reference standard. Moreover, RD9-based PCR directly on sputum detected 7(6.0%) individuals who were sputum culture negative for M. tuberculosis.

CONCLUSION

M. tuberculosis was detected in stool of individuals living with HIV who were negative for sputum smear microscopy and culture. Hence, examination of stool samples alongside with sputum samples increases the detection of PTB in individuals living with HIV.

[Pulmonary tuberculosis among hospitalized patients in Brazzaville: impact of late diagnosis of HIV infection on radiographic abnormalities]

L’objectif de notre étude était de décrire les différents aspects radiographiques de la tuberculose pulmonaire selon le degré de l’immunodépression chez les patients VIH. Nous rapportons une étude rétrospective de 80 patients VIH positif non traités présentant une tuberculose pulmonaire, hospitalisés dans le service de Pneumo-phtisiologie de Brazzaville de Janvier 2013 à Janvier 2014. Notre échantillon était composé de 44 femmes (55%) et 36 hommes (45%) soit un sex ratio de 0,81. La moyenne d’âge était de 37,5±9,17ans, la moyenne du Taux de CD4 était de 153,13±86,6cell/mm³. La microscopie des expectorations à la recherche des bacilles acido-alcoolo-résistants était positive dans 75% des cas chez les patients ayant un taux de lymphocytes T CD4>200cell/ mm³. Les adénopathies médiastinales, les atteintes moyennes, inferieures du champ pulmonaire et la miliaire étaient plus fréquentes chez les patients ayant un taux de lymphocytes T CD4< 200cell/ mm³. L’immunodépression sévère est significativement associée à la présentation radiographique atypique de la tuberculose.

Innate and Adaptive Cellular Immune Responses to Mycobacterium tuberculosis Infection

Host resistance to Mycobacterium tuberculosis (Mtb) infection requires the coordinated efforts of innate and adaptive immune cells. Diverse pulmonary myeloid cell populations respond to Mtb with unique contributions to both host-protective and potentially detrimental inflammation. Although multiple cell types of the adaptive immune system respond to Mtb infection, CD4 T cells are the principal antigen-specific cells responsible for containment of Mtb infection, but they can also be major contributors to disease during Mtb infection in several different settings. Here, we will discuss the role of different myeloid populations as well as the dual nature of CD4 T cells in Mtb infection with a primary focus on data generated using in vivo cellular immunological studies in experimental animal models and in humans when available.

HIV/AIDS Related Respiratory Diseases

Lungs are the most commonly involved organ by HIV/AIDS related diseases, and pulmonary infections are the main reasons for the increasing death rate from AIDS. Pathogens of HIV related pulmonary infections include parasites, fungi, mycobacteria, viruses, bacteria and toxoplasma gondii. According to international reports, pathogens have different geographical distribution, which is also closely related to the socioeconomic status of the region to produce varied AIDS related diseases spectra. For instance, in the United States, pneumocystis carnii pneumonia (PCP), tuberculosis and recurrent bacterial pneumonia (at least twice within 1 year) occur frequently in HIV infected patients. An international report published 10 years ago indicated that PCP is the most common and serious pulmonary opportunistic infections in HIV infected patients. Now its incidence has dropped with the application of antiretroviral treatment and preventive measures. PCP will continue to occur initially in patients who are aware of their HIV infection. In addition, HIV related viral and parasitic infections have been reported both domestically and internationally. In this section, the clinical manifestations and imaging findings of HIV related pulmonary infections are analyzed and discussed, which provide effective diagnosis basis, so as to reduce the incidence of HIV-related pulmonary infections.

Aetiology of pulmonary symptoms in HIV-infected smear negative recurrent PTB suspects in Kampala, Uganda: a cross-sectional study

Introduction

Previously treated TB patients with pulmonary symptoms are often considered recurrent TB suspects in the resource-limited settings, where investigations are limited to microscopy and chest x-ray. Category II anti-TB drugs may be inappropriate and may expose patients to pill burden, drug toxicities and drug-drug interactions.

Objective

To determine the causes of pulmonary symptoms in HIV-infected smear negative recurrent pulmonary tuberculosis suspects at Mulago Hospital, Kampala.

Methods

Between March 2008 and December 2011, induced sputum samples of 178 consented HIV-infected smear negative recurrent TB suspects in Kampala were subjected to MGIT and LJ cultures for mycobacteria at TB Reference Laboratory, Kampala. Processed sputum samples were also tested by PCR to detect 18S rRNA gene of P.jirovecii and cultured for other bacteria.

Results

Bacteria, M. tuberculosis and Pneumocystis jirovecii were detected in 27%, 18% and 6.7% of patients respectively and 53.4% of the specimens had no microorganisms. S. pneumoniae, M. catarrhalis and H. influenzae were 100% susceptible to chloramphenicol and erythromycin but co-trimoxazole resistant.

Conclusion

At least 81.5% of participants had no microbiologically-confirmed TB. However our findings call for thorough investigation of HIV-infected smear negative recurrent TB suspects to guide cost effective treatment.

Pretreatment and posttreatment radiography in patients with pulmonary tuberculosis with and without human immunodeficiency virus infection

PURPOSE

The purpose of this study was to determine differences in pretreatment and posttreatment radiographic findings in pulmonary tuberculosis (PTB) patients with and without human immunodeficiency virus (HIV) infection.

MATERIALS AND METHODS

All patients were reviewed in terms of pre- and posttreatment radiographic findings comparing non-HIV-related versus HIV-related PTB.

RESULTS

Among 177 PTB patients, 38 (22%) were HIV seropositive and 139 (78%) were HIV-seronegative. The most common radiographic finding in non-HIV-related TB was reticular infiltration (66.2%), whereas the miliary pattern was the most common radiographic finding in HIV-related TB (34.2%). Radiographic findings in HIV related TB significantly presented with higher prevalence of the miliary pattern (P < 0.0001) and lower prevalence of reticular infiltration (P < 0.0001), cavitation (P = 0.003), and mass-like lesions (P = 0.039) compared to non-HIV-related TB. During the posttreatment period, normal chest radiographs were significantly present in the patients who had HIV-seropositivity, the miliary pattern, and sputum negative for acid-fast bacilli during the pretreatment period (P < 0.05).

CONCLUSION

Pretreatment radiographic features of HIV-related TB had a significantly higher prevalence of the miliary pattern and lower prevalence of reticular infiltration, cavitation, and mass-like lesions. HIV-related TB and the miliary pattern seen by pretreatment radiography were significantly associated with normal chest radiographs during the posttreatment period.

HIV and tuberculosis: a deadly human syndemic

A syndemic is defined as the convergence of two or more diseases that act synergistically to magnify the burden of disease. The intersection and syndemic interaction between the human immunodeficiency virus (HIV) and tuberculosis (TB) epidemics have had deadly consequences around the world. Without adequate control of the TB-HIV syndemic, the long-term TB elimination target set for 2050 will not be reached. There is an urgent need for additional resources and novel approaches for the diagnosis, treatment, and prevention of both HIV and TB. Moreover, multidisciplinary approaches that consider HIV and TB together, rather than as separate problems and diseases, will be necessary to prevent further worsening of the HIV-TB syndemic. This review examines current knowledge of the state and impact of the HIV-TB syndemic and reviews the epidemiological, clinical, cellular, and molecular interactions between HIV and TB.

Aspectos tomográficos da tuberculose pulmonar em pacientes adultos com AIDS

OBJETIVO: Este trabalho tem como finalidade descrever os achados tomográficos da tuberculose pulmonar em pacientes adultos com AIDS atendidos no serviço de radiologia de um hospital de referência em doenças infecciosas, procurar associações desses achados e a contagem de CD4. MATERIAIS E MÉTODOS: Foram estudados 45 pacientes por meio de tomografia computadorizada de tórax durante quatro anos. RESULTADOS: Foram encontrados linfonodomegalia mediastinal e/ou hilar em 31 (68,8%) dos casos, derrame pleural em 29 (64,4%), nódulos centrolobulares de distribuição segmentar em 26 (57,7%), consolidação em 24 (53,3%), confluência de micronódulos em 17 (37,7%), nódulos mal definidos com distribuição centrolobular em 16 (35,5%), padrão de "árvore em brotamento" em 13 (28,9%), espessamento de parede brônquica em 12 (26,6%), cavidade de parede espessa em 10 (22,2%), nódulos miliares em 9 (20%) e bronquiectasias cilíndricas em 6 (13,3%). Dos 45 pacientes, 35 (77,8%) apresentaram CD4 < 200 cel/mm³ e 10 (22,2%) apresentaram CD4 > 200 cel/mm³. CONCLUSÃO: Concluímos que neste estudo, diversamente do descrito na literatura, linfonodomegalia mediastinal e/ou hilar e consolidação foram significativamente mais frequentes em pacientes com CD4 > 200 cel/mm³. No entanto, linfonodos com centro hipodenso foram mais frequentemente observados em pacientes com severa imunodepressão, ou seja, CD4 < 200 cel/mm³.

Manifestation of tuberculosis in patients with human immunodeficiency virus: a large Indian study

BACKGROUND:

Government Hospital of Thoracic Medicine, Tambaram Sanatorium, Chennai, is the largest HIV-care center in South East Asia. As many as 29,300 HIV patients visited this center at least once in the year 2005 for care and support.

OBJECTIVES:

Clinical manifestations and the modes of presentation of tuberculosis were assessed among 12,750 adult and adolescent patients with human immunodeficiency virus (HIV) attending the hospital for the first time.

MATERIALS AND METHODS:

Database of Hospital Information System, specially evolved for managing patients afflicted with tuberculosis and HIV, was utilized. The particulars confined to patients with tuberculosis and HIV co-infection who visited the hospital for the first time from January to December 2005 were considered for the analysis. Proportion test and Chi-square test with Yates correction were done.

RESULTS:

As many as 12,750 adult and adolescent HIV-confirmed patients were screened for the possible presence of tuberculosis. Out of them, 4,383 (34.4%) patients had tuberculosis. Among them, 2,448 (55.9%) had pulmonary tuberculosis, and the remaining 1,935 (44.1%) had either disseminated or extra-pulmonary tuberculosis (P<0.001). Positive sputum-smear microscopy for acid fast bacilli was evident in 1,363 (31.1%) patients; however, it was significantly lower compared to positive smear rate of 44% in HIV patients (P< 0.001).

CONCLUSION:

Tuberculosis was found to be the predominant co-infection among the symptomatic patients infected with HIV attending the largest care center for the first time in India. Advanced tuberculosis, disseminated tuberculosis and sputum smear negative pulmonary tuberculosis were the presenting clinical manifestations in 44% of the patients, as they had moderate to advanced immunosuppression. Early detection of tuberculosis co-infection is absolutely necessary.

HIV-associated opportunistic pneumonias

Among the HIV-associated pulmonary complications, opportunistic pneumonias are major causes of morbidity and mortality. The spectrum of HIV-associated opportunistic pneumonias is broad and includes bacterial, mycobacterial, fungal, viral and parasitic pneumonias. Bacterial pneumonia is the most frequent opportunistic pneumonia in the United States and Western Europe while tuberculosis is the dominant pathogen in sub-Saharan Africa. With the use of combination antiretroviral therapy and prophylaxis, the incidence of Pneumocystis pneumonia (PCP) has declined. Nevertheless, PCP continues to occur in persons who are unaware of their HIV infection, those who fail to access medical care, and those who fail to adhere to antiretroviral therapy or prophylaxis. Although pneumonias due to Cryptococcus neoformans, Histoplasma capsulatum, Coccidioides immitis, cytomegalovirus and Toxoplasma gondii are less frequent, their presence in the lung is often indicative of disseminated disease and is associated with significant mortality.

Prevalence and its predictors of extrapulmonary involvement in patients with pulmonary tuberculosis

Extrapulmonary organ involvement in human immunodefiaency virus (HIV)-infected patients with pulmonary tuberculosis (TB) is reported to be 26%, however, the clinical predictors of extrapulmonary involvement in pulmonary TB patients has not been reported yet. We tried to determine the clinical predictors of presence of extrapulmonary involvement in patients with pulmonary TB. Cross-sectional study was performed including all adult patients with culture-proven pulmonary TB diagnosed between January 1, 2004 and July 30, 2006, at a tertiary referral hospital in South Korea. The presence of extra-pulmonary TB involvement was diagnosed based on bacteriological, pathological, or clinical evidence. Among 320 patients with a culture-proven pulmonary TB, 40 had extrapulmonary involvement. Patients with bilateral lung involvement were more likely to have extrapulmonary involvement, with an adjusted odds ratio (OR) of 4.21 (95% confidence interval [CI], 1.82-9.72), while patients older than 60 yr (adjusted OR, 0.27; 95% CI, 0.08-0.89), patients with cavitary lesions (adjusted OR, 0.37; 95% CI, 0.16-0.84), and with higher levels of serum albumin (adjusted OR, 0.45; 95% CI, 0.25-0.78) had less frequent involvement. Clinicians should be aware of the possibility of extrapulmonary involvement in TB patients with bilateral lung involvement without cavity formation or lower levels of serum albumin.

Radiographic improvement and its predictors in patients with pulmonary tuberculosis

OBJECTIVES

The aim of this study was to analyze changes in the extent of radiographic lesions with treatment in patients with pulmonary tuberculosis (TB) and, further, to identify clinical and radiographic factors related to radiographic response.

METHODS

A prospective cohort study including patients with culture-proven pulmonary TB was performed. The posterior-anterior view films of the chest that had been taken at the time of diagnosis and at 6 months after the initiation of treatment were compared. We expressed the extents of the lesions as percentages involving the parenchyma compared with the remaining normal parenchyma.

RESULTS

Among 135 patients enrolled, three failed to achieve smear conversion of sputa after 6 months of treatment. The extent of radiographic lesions decreased from 22.8% at the time of diagnosis to 10.5% after 6 months of treatment. Through the multiple regression model, we found that increasing age (p=0.034), previous history of TB (p=0.016), presence of cavity (p=0.016) or fibrotic lesion (p=0.009), and multidrug-resistant TB (p=0.002) were significantly associated with a poor radiographic response.

CONCLUSION

Patients with less-prominent radiographic improvement and sustained negative tuberculous cultures of the sputa could be closely observed without ordering unnecessary chest radiographs or mycobacterial cultures as well as prolonging treatment.

Pulmonary tuberculosis: virulence of Mycobacterium africanum and relevance in HIV co-infection

Although Mycobacterium africanum is being isolated in a significant proportion of cases of pulmonary tuberculosis in West Africa, its pathogenic potential remains a matter of discussion. Recent reports leave the question of whether M. africanum causes more severe pathology than M. tuberculosis or resembles opportunistic pathogens and might gain importance in the course of the HIV pandemic. Patients with pulmonary tuberculosis associated with M. africanum (n=556) and M. tuberculosis (n=1350) were studied in Ghana, West Africa, and compared regarding self-reported signs and symptoms, chest radiography, HIV status, mycobacterial drug resistance and mycobacterial clustering as determined by spoligotyping and IS6110 fingerprints. The rate of M. africanum infections was similar in HIV-positive (27%) and HIV-negative (30%) patients. M. africanum clustered less than M. tuberculosis (21% vs 79%; OR, 0.38; 95% CI, 0.3-0.5; p<0.001) corresponding to its lower prevalence (29% vs 70%). Clinically and radiographically, no significant differences were found except that M. africanum caused lower-lobe disease less frequently than M. tuberculosis (OR, 0.39; 95% CI, 0.2-0.7; Pc=0.01), whereby this association applied to HIV-negative patients only. No difference in virulence, as assessed by the severity of radiological presentation, was found when the two M. africanum subtypes West African 1 and West African 2 were compared. In the population studied, M. africanum closely resembled M. tuberculosis in pathology and cannot be considered an opportunistic pathogen.

Cavitary pulmonary disease

A pulmonary cavity is a gas-filled area of the lung in the center of a nodule or area of consolidation and may be clinically observed by use of plain chest radiography or computed tomography. Cavities are present in a wide variety of infectious and noninfectious processes. This review discusses the differential diagnosis of pathological processes associated with lung cavities, focusing on infections associated with lung cavities. The goal is to provide the clinician and clinical microbiologist with an overview of the diseases most commonly associated with lung cavities, with attention to the epidemiology and clinical characteristics of the host.

Laboratory diagnosis of pulmonary tuberculosis in TB and HIV endemic settings and the contribution of real time PCR for M. tuberculosis in bronchoalveolar lavage fluid

BACKGROUND

Tuberculosis (TB) in Africa is increasing because of the human immunodeficiency virus (HIV) epidemic, and in HIV/AIDS patients it presents atypically. Pulmonary tuberculosis (PTB) in Africa is mainly diagnosed clinically, by chest radiograph or by sputum smear for acid fast bacilli (AFB).

METHODS

We evaluated in 120 HIV-infected patients with chest infection the diagnostic accuracy of AFB smear of sputum and bronchoalveolar lavage (BAL) fluid, sputum Mycobacterium tuberculosis (MTB) culture, real-time PCR and MycoDot serological test, using MTB culture of BAL fluid as gold standard. We correlated PCR cycle threshold values (C(T)) to the culture results. Retrospectively, we evaluated the development of active TB in patients with positive PCR but negative culture.

RESULTS

Culture of BAL fluid identified 28 patients with PTB. Fifty-six patients could not produce adequate sputum. Sputum AFB smear and the serological test had sensitivities of 66.7% and 0%, respectively. PCR with C(T) 40 was positive in 73 patients, 27 of whom were also TB culture positive (96.4% sensitivity and 52.3% specificity of PCR). PCR with C(T) 32 had sensitivity of 85.7% and specificity of 90.9% to diagnose PTB in BAL. No patients with positive PCR but negative culture developed active TB during 18 months follow-up.

CONCLUSION

In these HIV-infected patients, AFB smear and serology had very low sensitivities. PCR of BAL with C(T) value 32 had improved specificity to diagnose active PTB. A prospective follow-up study is warranted in TB/HIV endemic settings, applying real time PCR to both sputum and BAL.

[Mechanisms and causes of death in 143 Vietnamese HIV-infected patients hospitalized for tuberculosis]

OBJECTIVE OF THE STUDY

To know the mechanisms and causes of death in Vietnamese VIH-infected patients hospitalized for tuberculosis.

METHODS

Retrospective analysis of a monocentric cohort of 143 consecutive co infected patients admitted to Pham Ngoc Thach Hospital, in Ho Chi Minh City, between January 2004 and November 2004.

MAIN RESULTS

All the patients were HIV-infected and AFB smear positive. The CD4 T lymphocyte count was 55/mm3 and the body mass index was 15.8 +/- 2 kg/m2. During the first three months after hospital admission and tuberculosis diagnosis, the percentage of deaths was 28.7% (41/143). The mechanisms of deaths were: progressive cachexia, acute respiratory failure, cardiogenic or bacteremic shock, coma and unexpected cardio respiratory arrest. The causes of death were tuberculosis (particularly mechanical complications such as compressive pneumothorax, pericarditis or pleuritis), metabolic disorders (mainly hyponatrémie and dyskaliema) and associated infection. In multivariate analysis, two parameters (available at admission) were predictive of short-term death: anemia (p=0.024) and hyponatrémie (p=0.026).

CONCLUSION

The short term mortality of co infected patients with AIDS and tuberculosis remains high in developing countries. However, some causes of death such as compressive pneumothorax-pleuritis-pericarditis, metabolic disorder or even associated opportunistic infection i. e. pneumocystosis may be prevented or cured. Consequently, such patients must be carefully monitored and more particularly those with severe anemia and/or hyponatrémie at admission. Similarly appropriate diagnostic algorithms must be used in case of unfavorable evolution particularly to diagnose curable complication.

Tuberculin skin testing in patients with HIV infection: limited benefit of reduced cutoff values

BACKGROUND

When determining eligibility for isoniazid preventive therapy of human immunodeficiency virus (HIV)-infected patients, the cutoff value of the tuberculin skin test (TST) is often reduced from an induration of 10 mm in diameter to one of 5 mm in diameter to compensate for loss of sensitivity. The effectiveness of this reduction depends on the underlying mechanism: a gradual decrease in skin test responsiveness with decreasing immunocompetence or an all-or-nothing switch to complete anergy. No published studies have assessed this directly in patients with tuberculosis.

METHODS

We performed a cross-sectional study of TST responses and HIV infection among patients with sputum smear-positive pulmonary tuberculosis in 6 hospitals in Tanzania. Skin test anergy was defined as a TST reaction < or =2 mm in diameter.

RESULTS

Of 991 patients with complete results, 451 (45.5%) had HIV infection. Anergy was observed in 111 (24.6%) of 451 HIV-infected patients and 18 (3.3%) of 540 HIV-uninfected patients (P<.001). The reaction size distributions among nonanergic HIV-infected and uninfected patients showed a limited difference (mean diameter +/- standard deviation, 15.9 +/- 5.0 mm and 16.8 +/- 3.8 mm, respectively; P=.048). The sensitivity of the TST among HIV-uninfected patients was 91.1% at a cutoff value of 10 mm and 95.2% at a cutoff value of 5 mm. The sensitivity of the TST among HIV-infected patients was 64.3% at a cutoff value of 10 mm and 71.2% at a cutoff value of 5 mm; the sensitivity of the TST was 67.6% and 74.5%, respectively, after adjustment for tuberculosis-specific anergy.

CONCLUSION

In subjects with tuberculosis disease and HIV infection, loss of TST sensitivity is predominantly attributable to anergy (i.e., an all-or-nothing phenomenon). The decrease in the proportion of false-negative TST results obtained by reducing the cutoff value from 10 mm to 5 mm is limited.

Diagnosed tuberculosis during the follow-up of a cohort of human immunodeficiency virus-infected children in Abidjan, Côte d'Ivoire: ANRS 1278 study

INTRODUCTION

Most data on tuberculosis in human immunodeficiency virus (HIV)-infected children in Africa come from hospital-based and cross-sectional studies.

OBJECTIVES

To estimate the incidence of tuberculosis in HIV-infected children participating in an observational cohort.

METHODS

HIV-infected children in Abidjan, Côte d'Ivoire, are followed in a prospective cohort. At enrollment, all children had a physical examination, CD4 lymphocyte counts, chest radiograph and a tuberculin test. Quarterly follow-up visits are organized. All patients with suspected tuberculosis undergo specific investigations including gastric aspiration and culture. All isolates are tested for susceptibility.

RESULTS

From October 2000 to December 2003, 129 girls and 153 boys were recruited. Of children without a current or previous diagnosis of tuberculosis, 6.5% (13 of 199) had a tuberculin test result of >5 mm, compared with 17.5% of children (10 of 57) with current or previous tuberculosis (P < 0.02). Forty-eight children (17%) had a history of treated tuberculosis, and 27 children were being treated for tuberculosis at enrollment or during the first month of follow-up. Eleven children were diagnosed with tuberculosis after the first month of follow-up, and the diagnosis of mycobacterial infection was confirmed in 7 cases. Of 5 tested isolates of Mycobacterium tuberculosis, 3 were resistant to at least 1 antitubercular drug. Cumulative incidence of tuberculosis was 2060/100,000 at 12 months, 3390/100,000 at 2 years and 5930/100,000 at 3 years. The 3-year risk was 12,400/100,000 in immunocompromised children (CD4 <15%) and 3300/100,000 in other children (P < 0.0001).

CONCLUSION

The risk of tuberculosis among HIV-infected children in Côte d'Ivoire is strongly associated with the degree of immunodeficiency in HIV infection.

Tuberculosis and HIV disease: two decades of a dual epidemic

The HIV epidemic is currently in its third decade without any sign of abating. Tuberculosis (TB) is responsible for a third of all AIDS deaths, 99% of which occur in developing countries. The two epidemics fuel each other, together making up the leading infectious causes of mortality worldwide. Tuberculosis-HIV coinfection presents special diagnostic and therapeutic challenges and constitutes an immense burden on the health care systems of heavily infected countries. Despite major gains that have been made in the past two decades, important questions still remain. To cope with the challenge of TB-HIV coinfection, further research in the design of diagnostic tests for tuberculosis, detection of drug resistant Mycobacterium tuberculosis strains in HIV-positive people, as well as development of more effective therapeutic agents and vaccines are urgently needed. It has become evident that this dual epidemic will persist unless comprehensive measures are instituted through the provision of sufficient funding in addition to expanding and strengthening current control strategies adopted by governments and international organizations.

Predictors of HIV/AIDS among individuals with tuberculosis: health and policy implications

The purpose of this report was retrospectively to assess the application of clinical predictors (i.e. signs and symptoms) for the diagnosis of the human immunodeficiency virus (HIV) infections, including the acquired immunodeficiency syndrome (AIDS), among tuberculosis (TB)-positive subjects enrolled within an urban heterosexual sero-discordant couple (one partner HIV-positive and the other HIV-negative) cohort study at an HIV prevention and research centre in Lusaka, Zambia. Available medical, clinical and laboratory records from 1994 to mid-1998 were reviewed, with follow-up visits to the local chest clinics and sputum analyses laboratories instituted as additional quality assurance measures. A nested case-control study was employed. The World Health Organization clinical case definition for HIV/AIDS (WHOCCDA) was observed to be significantly more likely to predict HIV/AIDS among TB-positive HIV-positive subjects than TB-positive HIV-negative subjects. Therefore, this report documents the relative effectiveness of the WHOCCDA in predicting HIV/AIDS cases and discusses the health and policy implications, especially for the developing world which accounts for a significant proportion and impact of HIV/AIDS. Further research studies based on prospective randomized controlled trails or other rigorous evaluation strategies are warranted to substantiate these findings.

Rapid detection of active and latent tuberculosis infection in HIV-positive individuals by enumeration of Mycobacterium tuberculosis-specific T cells

OBJECTIVES

An accurate test for Mycobacterium tuberculosis infection is urgently needed. The tuberculin skin test (TST) lacks sensitivity, particularly in HIV-infected individuals, and has poor specificity because of antigenic cross-reactivity with Bacillus Calmette-Guérin (BCG) vaccination. ESAT-6 and CFP-10 are antigens expressed in Mycobacterium tuberculosis, but not in Mycobacterium bovis BCG and most environmental mycobacteria. We investigated whether T cells specific for these antigens could serve as accurate markers of M. tuberculosis infection in an area of high tuberculosis and HIV prevalence.

METHODS

Using the rapid ex-vivo enzyme-linked immunospot (ELISPOT) assay for IFN-gamma, we enumerated T cells specific for ESAT-6, CFP-10 and purified protein derivative (PPD) in blood samples from 50 Zambian tuberculosis patients, 75 healthy Zambian adults, and 40 healthy UK residents. TSTs were performed in 49 healthy Zambian adults.

RESULTS

All (100%; n = 11) and 90% (n = 39) of HIV-negative and HIV-positive tuberculosis patients, respectively, had detectable ESAT-6- or CFP-10-specific T cells. The ESAT-6/CFP-10-based ELISPOT assay was positive in 37 out of 54 HIV-negative healthy Zambians, suggesting a 69% prevalence of latent M. tuberculosis infection. Fewer HIV-positive Zambians possessed ESAT-6/CFP-10-specific T cells, but the impact of HIV infection was less on this assay than on the PPD-based ELISPOT or TST.

CONCLUSION

The ESAT-6/CFP-10-based ELISPOT assay detects active tuberculosis in HIV-positive individuals with high sensitivity. It is more specific, and possibly more sensitive, than PPD-based methods of detecting latent M. tuberculosis infection, and may potentially improve the targeting of isoniazid preventative therapy to HIV-positive individuals with latent tuberculosis infection.

Association of high HIV-1 RNA levels and homozygosity at HLA class II DRB1 in adults coinfected with Mycobacterium tuberculosis in Harare, Zimbabwe

HIV-1 mRNA levels (virus load) were quantified for 191 pulmonary tuberculosis (TB) patients and 132 HIV-1 seropositive controls. Human leukocyte antigen (HLA) class I and II genes were typed for 188 patients and 121 HIV-1 seropositive controls. The mean log virus load was higher among cases than HIV-1 seropositive controls (p < 0.0001). Among the controls, mean log virus load was higher among males than females (p = 0.04). There was no association between virus load and homozygosity at HLA class I and II among the controls. In contrast, among the cases, HLA-DRB1 homozygosity was associated with high virus load (p = 0.008), conferring risk for rapid progression to AIDS, thus lending support to the heterozygote advantage hypothesis. The observed decreased virus load in HLA-DRB-1 heterozygotes may be due to a better control of M. tb. infection in the context of HIV-1 disease.

Lung radiology in the tropics

A high-quality chest radiograph and a timely, accurate report are often impossible in the tropics. Rationale matching of service to need, enthusiasm, commitment, and exploitation of information technology all go some way toward enabling patients with pulmonary disease to be imaged. The radiologic findings reflect the high preponderance of infectious disease. TB, HIV, and TB modified by HIV may be "routine" features in some parts of the tropics. Elsewhere, infestation with ameba, hydatid, and strongyloidosis, paragonimiasis, and melioidosis accounts for radiographic signs. The key is to have these conditions firmly in mind when reading tropical radiographs and be aware that the pattern of disease may be different between the patient from the tropics and the more familiar patient from downtown New York.

Tuberculosis in patients with myelodysplastic syndromes

AIM

The purpose of our study was to describe radiological manifestations of tuberculosis in patients with myelodysplastic syndromes.

MATERIALS AND METHODS

Chest radiographs and CTs of 12 patients with tuberculosis among 195 consecutive patients with myelodysplastic syndrome, proved by bone marrow biopsy, were reviewed. Six of the 12 patients presented with tuberculosis and were subsequently found to have myelodysplastic syndrome.

RESULTS

Chest radiographs and CTs revealed pulmonary tuberculosis in all 12 patients and extrapulmonary tuberculous involvement in six (50%). Initial chest radiographic findings of pulmonary tuberculosis included a primary pattern (n = 6), a post-primary pattern (n = 3), a miliary pattern (n = 1), atypical infiltrates (n = 1) and normal radiograph (n = 1). Tuberculosis involved extrathoracic lymph nodes (n = 5), liver (n = 2), spleen (n = 2), kidney (n = 2), bowel (n = 2), pericardium (n = 2) peritoneum (n = 1) and rib (n = 1).

CONCLUSION

Tuberculosis is a relatively common cause of infection in patients with myelodysplastic syndromes. The radiological appearance of pulmonary tuberculosis in myelodysplastic syndromes is often a primary pattern, and there is frequently extrapulmonary involvement.

A COMPARATIVE STUDY OF CHEST RADIOGRAPHIC FEATURES BETWEEN HIV SEROPOSITIVE AND HIV SERONEGATIVE PATIENTS OF PULMONARY TUBERCULOSIS

Chest radiographic appearance of pulmonary tuberculosis (TB) in Human Immunodeficiency Virus (HIV) positive patients was reviewed. A study group of 50 HIV +ve cases and a control group of 100 HIV -ve cases were analysed. The chest radiographs of HIV seropositive group showed significantly higher incidence of thoracic lymphadenopathy (36% vs 8%, P<.001), pleural effusion (28% vs 10%, P<.01) and miliary pattern (12% vs 2%, P<.05) as compared to the seronegative group. Cavitation was less common in the seropositive group (8% vs 35%, P<.001) than the seronegative group. Upper zone involvement was significantly less common in the study group (38% vs 77%, P<.001) as compared to the control group.

Radiology of pneumonia

Chest radiography is the imaging technique of choice in evaluating patients with suspected pneumonia because of its low radiation dose, low cost, and wide accessibility. In daily practice, radiographs are used to confirm the clinical diagnosis of pneumonia, characterize the extent and severity of disease, search for complications such as empyema, monitor the response to therapy, and examine for possible alternative or additional diagnoses. Although CT scan has no defined role in the routine assessment of patients with either community-acquired or nosocomial pneumonias, its advantages of superior contrast resolution and cross-sectional display can often be helpful in the analysis of complex cases, particularly when radiographic evidence of associated central obstruction, cavitation, lymphadenopathy, or empyema is equivocal. In the immunocompromised patient population, high-resolution CT has been shown to be more sensitive than plain film radiography in the early detection of pulmonary infections.

HIV and tuberculosis in rural sub-Saharan Africa: a cohort study with two year follow-up

The objective was to examine the effect of HIV seropositivity on outcomes in tuberculosis (TB) patients in a rural African setting, including rates of TB relapse, other morbid events and mortality. The study setting was a district level hospital in Mzuzu, Malawi. Adult TB patients presenting between November 1991 and May 1993 were included in the study. Treatment was given according to national guidelines. Patients with smear-positive TB received 8 months of rifampicin-containing short-course chemotherapy. Patients with smear-negative or extrapulmonary TB received 12 months of 'standard' treatment. Subjects were followed until they died or until the study concluded (December 1994). There were 225 eligible patients; 187 were tested for HIV and enrolled in the study (66.8% HIV seropositive). Ninety-four percent had complete follow-up information. The cure rate in smear-positive patients who survived to the end of treatment was over 90% and not significantly affected by HIV. Disorders of the gastrointestinal, neurological and dermatological systems were significantly more common in HIV-seropositive patients. HIV had a significant effect on the risk of relapse of TB (hazard ratio [HR] = 10.55 [95% CI 1.38, 80.93]) and on all-cause mortality (HR = 2.81 [95% CI 1.63, 4.64]). Despite high HIV prevalence, high rates of TB cure are achievable using the usual treatment protocols. However, excess TB relapse, other illnesses and mortality associated with HIV seropositivity have serious implications for TB control. There is an urgent need to identify effective intervention strategies aimed at prevention, early diagnosis and treatment of these illnesses.

Comparison between human immunodeficiency virus positive and negative patients with tuberculosis in Southern Brazil

The objective of this study is to determine the different characteristics of human immunodeficiency virus (HIV) positive and negative patients treated for tuberculosis (TBC) in a tertiary hospital in Southern Brazil. We conducted a retrospective cohort study over a 5-year period, from January 1992 through December 1996. We reviewed medical charts of patients from our institution who received TBC treatment. We reviewed 167 medical charts of patients with confirmed TBC. HIV positivity was detected in 74 patients. There were statistically significant difference between HIV positive and negative patients in sex and age. HIV-infected patients showed significantly more signs of bacteremia than HIV-negative patients. Extra-pulmonary TBC was present respectively in 13 (17.6%) and 21 (22.6%) HIV positive and negative patients. There was a significant difference between chest radiograph presentation in HIV positive and negative patients. There were significantly lower hematocrit, hemoglobin, leukocyte and lymphocyte levels in HIV-positive compared to HIV-negative patients. Outcome was significantly different in the two groups with a death rate of 36.5% and 10.8% in HIV-positive and in HIV-negative patients. The difference between HIV positive and negative patients may have importance in the diagnosis, management and prognosis of patients with TBC.

A new, clinically-based algorithm for the diagnosis of HIV in African tuberculosis patients: cross-sectional analysis from Mzuzu, Malawi

We aimed to create an improved, clinically-based algorithm for the diagnosis of HIV in tuberculosis (TB) patients. Cross-sectional analysis was performed on data from adult TB patients consecutively diagnosed at a Malawian district level hospital. Of 225 patients, 187 with valid HIV results were included in the study. Sixty-seven per cent were HIV seropositive. Urban address, history of skin rash and sexually transmitted diseases (STDs) and, on examination, oral candidiasis and lymphadenopathy, were associated with HIV co-infection. Using these clinical characteristics, a case definition for HIV was constructed. The Mzuzu clinical case definition was highly sensitive (86%). The area under the receiver operating characteristic (ROC) curve was 0.81, significantly larger than existing World Health Organization (WHO) clinical case definitions. The Mzuzu definition is proposed for further evaluation in settings where HIV serological testing is not readily available.

Tuberculosis in Africa: clinical presentation and management

In the last decade, sub-Saharan Africa has experienced an explosive increase in tuberculosis (TB) cases, largely as a result of the co-epidemic of human immunodeficiency virus (HIV) infection. This article reviews the essential background epidemiology of TB in sub-Saharan Africa. The clinical features and diagnostic problems of pulmonary/extrapulmonary TB in adults and children are discussed, particularly in relation to HIV infection. Different treatment regimens, their cost, adverse reactions, the ways in which HIV infection influences treatment response and the extent of drug resistance are reviewed. The recommended approaches to TB control in Africa, including methods used to prevent TB through Bacillus Calmette-Guerin and chemoprophylaxis are examined. The success achieved by good National TB Control Programmes in some African countries allows cautious optimism that this epidemic can be controlled.

Mycobacterial complications of HIV infection

Tuberculosis is the most common opportunistic infection worldwide and is caused by the only readily transmissible pathogen among persons with HIV infection. If treatment is initiated promptly and is supervised appropriately, cure, fortunately, is highly likely. Isoniazid preventive therapy substantially reduces the risk of tuberculosis in persons with HIV infection. Of the nontuberculous mycobacteria, Mycobacterium avium complex (MAC) is the most frequent cause of disease; however, disseminated MAC disease usually is not seen until the CD4+ cell count is less than 50 cells/L. Newer agents, such as the macrolides and rifabutin, form the nucleus of treatment regimens and also are effective in preventing the disease.

The impact of human immunodeficiency virus on mortality of patients treated for tuberculosis in a cohort study in Zambia

We have examined the impact of human immunodeficiency virus (HIV) on mortality of patients treated for tuberculosis in a prospective study in Lusaka, Zambia. Patients with sputum smear-positive, miliary, or meningeal tuberculosis were prescribed 2 months' daily streptomycin, thiacetazone, isoniazid, rifampicin, and pyrazinamide followed by 6 months thiacetazone and isoniazid; others, 2 months streptomycin, thiacetazone and isoniazid followed by 10 months thiacetazone and isoniazid. 239 patients (65 HIV-negative and 174 HIV-positive) were followed to 2 years from start of treatment. The crude mortality rate ratio for HIV-positive compared with HIV-negative patients over 2 years was 5.00 (95% confidence interval 2.30-10.86). Median survival for HIV-positive patients from the start of treatment was 22 months. At least 34% of HIV-positive patients for whom cause of death was known died from tuberculosis, three-quarters of these during the first month of treatment. Risk factors for death in HIV-positive patients included multi-site tuberculosis, history of prolonged diarrhoea or fever, oral thrush, splenomegaly, anergy to tuberculin, low weight, anaemia or lymphopenia, and poor compliance with regimens containing rifampicin and pyrazinamide. Tuberculosis, even treated, was a major cause of death in patients with HIV infection.

Empiric antituberculosis treatment: benefits for earlier diagnosis and treatment of tuberculosis

SETTING

Tuberculosis may be diagnosed too late, especially in HIV-infected patients, with consequences on bacillus transmission and survival. Empiric antibuberculosis treatment (EATT) may be started before diagnosis of tuberculosis is confirmed. As rifampicin is a broad spectrum antibiotic, EATT including rifampicin may be effective in infections other than tuberculosis, leading to misdiagnosis.

OBJECTIVE

To define the efficiency criteria of EATT with or without rifampicin.

DESIGN

Between 1988 and 1991, 20 febrile patients with suspected tuberculosis (including 15 who were HIV-positive) were started on EATT in the absence of bacteriological or histological proof of tuberculosis. 10 patients (50%) received a 4-drug non-specific EATT including rifampicin, isoniazid, pyrazinamide and ethambutol, and 10 (50%), received a 3-drug specific EATT without rifampicin.

RESULTS

In 10 patients (50%), the diagnosis of tuberculosis was confirmed by positive cultures within a mean of 32 days (15-57 days) after the beginning of EATT (group TB 1). Of the 10 patients whose cultures remained negative, 4 (20%) became afebrile and showed improvement under EATT (group TB 2), and 6 (30%) remained febrile and did not improve (group No TB). Patients from groups TB 1 and TB 2 became afebrile within a mean of 11 days (1-54 days). This delay was not different between patients receiving specific or non-specific EATT. In patients receiving specific EATT, rifampicin was added to the initial 3-drug treatment after resolution of fever.

CONCLUSION

EATT appears to be a useful method for rapid presumptive diagnosis and treatment of tuberculosis.