HIV infection in patients with tuberculosis in Kinshasa, Zaire

A systematic review of utility of urine lipoarabinomannan in detecting tuberculosis among HIV-positive tuberculosis suspects

Sputum smear microscopy (SSM), though regarded as an inexpensive and popular method for detecting tuberculosis (TB), lacks adequate sensitivity, specifically in adult people living with HIV/AIDS (PLHIV). Urine lipoarabinomannan (LAM) is a promising diagnostic tool among PLHIV with CD4 cell count < 200 cells/μl. We attempted to review all the studies undertaken in identifying the utility of urine LAM in diagnosing TB, especially among PLHIV. We searched PubMed, Google Scholar, and MEDLINE databases for studies reporting diagnostic utility of urine LAM status in PLHIV, published in the last 20 years till December 2019. The keywords used for searching were “Tuberculosis,” “HIV/AIDS,” “Diagnosis,” “Screening” “Lipoarabinomannan,” and “Urine.” Our search resulted in 137 shortlisted citations, of which 67 related manuscripts were identified for detailed study. Based on inclusion and exclusion criteria, 37 studies were reviewed in detail. Average sample size of these studies was 464 (range = 81–2528; SD = 427). Crude average sensitivity of urine LAM in culture-confirmed TB cases was 44.1% (range = 8.3–93) while that of SSM was 38.6% (range = 14–65). However, sensitivity of urine LAM + SSM was 60.4% (range = 38.3–92.7), demonstrating the utility of SSM + urine LAM combination for detecting TB. Specificity was similar between urine LAM and SSM with 92.7% (range = 76–100) and 97.9% (range = 93.9–100), respectively. Majority of the studies demonstrated higher sensitivity of urine LAM in those with lesser the CD4 count, with immunocompromised and with debilitation who cannot produce self-expectorated sputum. We conclude that urine LAM is a potential diagnostic test in the algorithms involving immunocompromised, debilitated patients and specifically in PLHIV whose CD4 count is ≤100 cells/μl.

Urine-Based Nested PCR for the Diagnosis of Mycobacterium tuberculosis: A Comparative Study Between HIV-Positive and HIV-Negative Patients

Background

While tuberculosis (TB) can be diagnosed by microscopy and culture, the sensitivity of Ziehl-Neelsen staining is variable and culture results require 4 - 8 weeks to be determined. Polymerase chain reaction (PCR) and its modifications, including nested PCR, might be promising methods for the rapid diagnosis of TB.

Objectives

This study aimed to evaluate the performance of nested PCR on urine samples of human immunodeficiency virus (HIV)-positive and -negative patients with different manifestations of clinical TB.

Methods

In a prospective study, three early-morning urine samples from 100 patients with pulmonary TB (PTB) or extrapulmonary TB (EPTB) were evaluated using a molecular target with insertion element IS6110, specific to the Mycobacterium tuberculosis genome, and nested PCR was performed. The results were analyzed with SPSS version 22.

Results

A total of 100 patients, including 74 (74%) with PTB and 26 (26%) with EPTB, were enrolled. Positive smears were seen in 38 patients (38%). Lymph nodes were the most commonly involved organ in 14 of the 26 (53.8%) EPTB patients (13.5%). Seven (23.1%) of the EPTB patients were HIV-positive. Urine PCR was positive in only 28 patients (28%). Seven HIV-positive patients with PTB showed positive urine PCR results. Moreover, PCR results were positive in only one of the seven HIV-positive subjects with EPTB. Positive PCR results were found in 20 of the 73 HIV-negative patients (27.4%) and in 8 of the 27 HIV-positive patients (29.6%). Therefore, there was no significant difference between the HIV-negative and HIV-positive patients for urine PCR (sensitivity 29.6%, specificity 72.6%; positive and negative predictive values 28% and 72%, respectively; P = 0.138).

Conclusions

Nested PCR showed the same sensitivity in HIV-positive and HIV-negative patients. It can be applied as a rapid technique for the diagnosis of TB.

Modeling the dynamic relationship between HIV and the risk of drug-resistant tuberculosis

The emergence of highly drug-resistant tuberculosis (TB) and interactions between TB and HIV epidemics pose serious challenges for TB control. Previous researchers have presented several hypotheses for why HIV-coinfected TB patients may suffer an increased risk of drug-resistant TB (DRTB) compared to other TB patients. Although some studies have found a positive association between an individual's HIV status and his or her subsequent risk of multidrug-resistant TB (MDRTB), the observed individual-level relationship between HIV and DRTB varies substantially among settings. Here, we develop a modeling framework to explore the effect of HIV on the dynamics of DRTB. The model captures the acquisition of resistance to important classes of TB drugs, imposes fitness costs associated with resistance-conferring mutations, and allows for subsequent restoration of fitness because of compensatory mutations. Despite uncertainty in several key parameters, we demonstrate epidemic behavior that is robust over a range of assumptions. Whereas HIV facilitates the emergence of MDRTB within a community over several decades, HIV-seropositive individuals presenting with TB may, counterintuitively, be at lower risk of drug-resistant TB at early stages of the co-epidemic. This situation arises because many individuals with incident HIV infection will already harbor latent Mycobacterium tuberculosis infection acquired at an earlier time when drug resistance was less prevalent. We find that the rise of HIV can increase the prevalence of MDRTB within populations even as it lowers the average fitness of circulating MDRTB strains compared to similar populations unaffected by HIV. Preferential social mixing among individuals with similar HIV status and lower average CD4 counts among HIV-seropositive individuals further increase the expected burden of MDRTB. This model suggests that the individual-level association between HIV and drug-resistant forms of TB is dynamic, and therefore, cross-sectional studies that do not report a positive individual-level association will not provide assurance that HIV does not exacerbate the burden of resistant TB in the community.

Adjunctive tests for diagnosis of tuberculosis: serology, ELISPOT for site-specific lymphocytes, urinary lipoarabinomannan, string test, and fine needle aspiration

The diagnostic gold standard for active tuberculosis (TB) is the detection of Mycobacterium tuberculosis (MTB) by culture or molecular methods. However, despite its limited sensitivity, sputum smear microscopy is still the mainstay of TB diagnosis in resource-limited settings. Consequently, diagnosis of smear-negative pulmonary and extrapulmonary TB remains challenging in such settings. A number of novel or alternative techniques could provide adjunctive diagnostic use in the context of difficult-to-diagnose TB. These may be especially useful in certain patient groups such as persons infected with human immunodeficiency virus (HIV) and children, who are disproportionably affected by smear-negative and extrapulmonary disease and who are also most adversely affected by delays in TB diagnosis and treatment. We review a selection of these methods that are independent of nucleic acid amplification techniques and could largely be implemented in resource-limited settings in current or adapted versions. Specifically, we discuss the diagnostic use and potential of serologic tests based on detection of antibodies to MTB antigens; interferon gamma release assays using site-specific lymphocytes; detection of lipoarabinomannan, a glycolipid of MTB, in urine; the string test, a novel technique to retrieve lower respiratory tract samples; and fine needle aspiration biopsy of lymph nodes.

Sputum smear negative pulmonary tuberculosis: sensitivity and specificity of diagnostic algorithm

Background

The diagnosis of pulmonary tuberculosis in patients with Human Immunodeficiency Virus (HIV) is complicated by the increased presence of sputum smear negative tuberculosis. Diagnosis of smear negative pulmonary tuberculosis is made by an algorithm recommended by the National Tuberculosis and Leprosy Programme that uses symptoms, signs and laboratory results.

The objective of this study is to determine the sensitivity and specificity of the tuberculosis treatment algorithm used for the diagnosis of sputum smear negative pulmonary tuberculosis.

Methods

A cross-section study with prospective enrollment of patients was conducted in Dar-es-Salaam Tanzania. For patients with sputum smear negative, sputum was sent for culture. All consenting recruited patients were counseled and tested for HIV. Patients were evaluated using the National Tuberculosis and Leprosy Programme guidelines and those fulfilling the criteria of having active pulmonary tuberculosis were started on anti tuberculosis therapy. Remaining patients were provided appropriate therapy. A chest X-ray, mantoux test, and Full Blood Picture were done for each patient. The sensitivity and specificity of the recommended algorithm was calculated. Predictors of sputum culture positive were determined using multivariate analysis.

Results

During the study, 467 subjects were enrolled. Of those, 318 (68.1%) were HIV positive, 127 (27.2%) had sputum culture positive for Mycobacteria Tuberculosis, of whom 66 (51.9%) were correctly treated with anti-Tuberculosis drugs and 61 (48.1%) were missed and did not get anti-Tuberculosis drugs. Of the 286 subjects with sputum culture negative, 107 (37.4%) were incorrectly treated with anti-Tuberculosis drugs. The diagnostic algorithm for smear negative pulmonary tuberculosis had a sensitivity and specificity of 38.1% and 74.5% respectively. The presence of a dry cough, a high respiratory rate, a low eosinophil count, a mixed type of anaemia and presence of a cavity were found to be predictive of smear negative but culture positive pulmonary tuberculosis.

Conclusion

The current practices of establishing pulmonary tuberculosis diagnosis are not sensitive and specific enough to establish the diagnosis of Acid Fast Bacilli smear negative pulmonary tuberculosis and over treat people with no pulmonary tuberculosis.

Treatment outcome and mortality at one and half year follow-up of HIV infected TB patients under TB control programme in a district of South India

BACKGROUND

There is paucity of data from India on the impact of HIV related immunosuppression in response to TB treatment and mortality among HIV infected TB patients. We assessed the TB treatment outcome and mortality in a cohort of HIV infected TB patients treated with intermittent short course chemotherapy under TB control programme in a high HIV prevalent district of south India.

METHODOLOGY/ FINDINGS

Among 3798 TB patients registered for treatment in Mysore district from July 2007 to June 2008, 281 HIV infected patients formed the study group. The socio-demographic and treatment related data of these patients was obtained from TB and HIV programme records and patient interviews 19 months after TB treatment initiation by field investigators. Treatment success rate of 281 patients was 75% while in smear positive pulmonary tuberculosis cases it was 62%, attributable to defaults (16%) and deaths (19%). Only 2 patients had treatment failure. Overall, 83 (30%) patients were reported dead; 26 while on treatment and 57 after TB treatment. Association of treatment related factors with treatment outcome and survival status was studied through logistic regression analysis. Factors significantly associated with 'unfavourable outcome' were disease classification as Pulmonary [aOR-1.96, CI (1.02-3.77)], type of patient as retreatment [aOR-4.78, CI (2.12-10.76)], and non initiation of ART [aOR-4.90, CI (1.85-12.96)]. Factors associated with 'Death' were non initiation of ART [aOR-2.80, CI (1.15-6.81)] and CPT [aOR-3.46, CI (1.47-8.14)].

CONCLUSION

Despite the treatment success of 75% the high mortality (30%) in the study group is a matter of concern and needs immediate intervention. Non initiation of ART has emerged as a high risk factor for unfavourable treatment outcome and mortality. These findings underscore the importance of expanding and improving delivery of ART services as a priority and reconsideration of the programme guidelines for ART initiation in HIV infected TB patients.

Clinical and radiographic features of HIV-related pulmonary tuberculosis according to the level of immunosuppression

Medical charts and radiographs from 38 HIV-infected patients with positive cultures for Mycobacterium tuberculosis from sputum or bronchoalveolar lavage were reviewed in order to compare the clinical, radiographic, and sputum bacilloscopy characteristics of HIV-infected patients with pulmonary tuberculosis according to CD4+ lymphocyte count (CD4). The mean age of the patients was 32 years and 76% were male. The median CD4 was 106 cells/mm(3) and 71% had CD4 < 200 cells/mm(3). Sputum bacilloscopy was positive in 45% of the patients. Patients with CD4 < 200 cells/mm(3) showed significantly less post-primary pattern (7% vs. 63%; p = 0.02) and more frequently reported weight loss (p = 0.04). Although not statistically significant, patients with lower CD4 showed lower positivity of sputum bacilloscopy (37% vs. 64%; p = 0.18). HIV-infected patients with culture-confirmed pulmonary tuberculosis had a high proportion of non-post-primary pattern in thoracic radiographs. Patients with CD4 lower than 200 cells/mm(3) showed post-primary patterns less frequently and reported weight loss more frequently.

Diagnosis of smear-negative pulmonary tuberculosis in people with HIV infection or AIDS in resource-constrained settings: informing urgent policy changes

The HIV epidemic has led to large increases in the frequency of smear-negative pulmonary tuberculosis, which has poor treatment outcomes and excessive early mortality compared with smear-positive disease. We used a combination of systematic review, document analysis, and global expert opinion to review the extent of this problem. We also looked at policies of national tuberculosis control programmes for the diagnosis of smear-negative pulmonary tuberculosis to assess their coverage, identify the diagnostic difficulties, and find ways to improve the diagnosis of this type of tuberculosis, with a focus on resource-constrained settings with high HIV infection rates. We propose that the internationally recommended algorithm for the diagnosis of smear-negative pulmonary tuberculosis should be revised to include HIV status, severity of AIDS and tuberculosis, and early use of chest radiography in the decision tree. Increased use of promising methods of diagnosis such as sputum liquefaction and concentration and increased availability of fluorescence microscopy should be explored and encouraged. Culturing of sputum in resource-constrained settings with high HIV infection rates should also be encouraged, existing facilities should be made full use of and upgraded, and effective quality-assurance systems should be used. Innovative ways to address human resources issues involved in addressing the diagnostic difficulties are also needed. The development of rapid, simple, and accurate tuberculosis diagnostic tools with applicability at point of care and remote location is essential. To achieve these goals, greater political commitment, scientific interest, and investment are needed.

[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.

Sensitivity analysis and potential uses of a novel gamma interferon release assay for diagnosis of tuberculosis

Sputum smears for acid-fast bacilli (AFB) are the primary methods for diagnosis of tuberculosis (TB) in many countries. The tuberculin skin test (TST) is the primary method for diagnosis of latent TB infection (LTBI) worldwide. The poor sensitivity of the former and the poor specificity of the latter warrant the development of new tests and strategies to enhance diagnostic capabilities. We evaluated the sensitivity of an "in-tube" gamma interferon release assay (IGRA) using TB-specific antigens in comparison to the TST and the sputum smear for AFB in TB cases in South Africa. The sensitivity of the IGRA for TB was considered a surrogate of sensitivity in LTBI. Among 154 patients with a positive culture for Mycobacterium tuberculosis, the sensitivity of the IGRA for the diagnosis of TB varied by clinical subgroup from 64% to 82%, that of the TST varied from 85% to 94%, and that of two sputum smears for AFB varied from 35% to 53%. The sensitivity of the IGRA in human immunodeficiency virus (HIV)-infected TB cases was 81%. HIV-infected TB patients were significantly more likely to have indeterminate IGRA results and produced quantitatively less gamma interferon in response to TB-specific antigens than HIV-negative TB patients. The overall sensitivity of the TST in all TB cases was higher than that of the IGRA (90% versus 76%, respectively). The combined sensitivities of the TST plus IGRA and TST plus a single sputum smear were 96% and 93%, respectively. The TST combined with IGRA or with a single sputum smear may have a role in excluding the diagnosis of TB in some settings.

The cost to health services of human immunodeficiency virus (HIV) co-infection among tuberculosis patients in Sudan

OBJECTIVE

To compare the cost of managing HIV-positive and HIV-negative tuberculosis (TB) patients in Sudan.

METHODS

A prospective cohort of 1797 consecutive TB patients referred to the chest clinics within the general health services from March 1998 to March 2000 were included in this study. Patients were tested blindly for HIV; 1724 were HIV-negative and 73 were HIV-positive.

FINDINGS

The total cost associated with management of tuberculosis was significantly higher for HIV-positive, as compared with HIV-negative TB patients (105.08 US dollars versus 73.92, p=0.003). This difference was due mainly to greater costs for hospitalization of those HIV-positive, as compared with those HIV-negative (190.80 versus 141.00, p=0.001). The differences in cost for diagnostic tests, for drugs, for management of adverse reactions and for intercurrent symptoms were not significant (p>0.05) between HIV-positive TB patients and HIV-negative TB patients. Side effects of treatment were slightly more common among persons without HIV infection than among HIV-positive patients (14 and 9.6%, respectively). The total cost of management of HIV-positive patients in this series of patients was 6% of all costs for TB case management and the marginal cost attributable to HIV-positivity was 0.9% of the total cost.

CONCLUSION

The management of the HIV-positive TB case was more costly than that of the HIV-negative case in this stage of the HIV/AIDS epidemic in Sudan.

The impact of HIV/AIDS on the control of tuberculosis in India

Epidemics of HIV/AIDS have increased the tuberculosis (TB) case-load by five or more times in East Africa and southern Africa. As HIV continues to spread, warnings have been issued of disastrous AIDS and TB epidemics in "new-wave" countries, including India, which accounts for 20% of all new TB cases arising in the world each year. Here we investigate whether, in the face of the HIV epidemic, India's Revised National TB Control Program (RNTCP) could halve TB prevalence and death rates in the period 1990-2015, as specified by the United Nations Millennium Development Goals. Using a mathematical model to capture the spatial and temporal variation in TB and HIV in India, we predict that, without the RNTCP, HIV would increase TB prevalence (by 1%), incidence (by 12%), and mortality rates (by 33%) between 1990 and 2015. With the RNTCP, however, we expect substantial reductions in prevalence (by 68%), incidence (by 41%), and mortality (by 39%) between 1990 and 2015. In India, 29% of adults but 72% of HIV-positive adults live in four large states in the south where, even with the RNTCP, mortality is expected to fall by only 15% between 1990 and 2015. Nationally, the RNTCP should be able to reverse the increases in TB burden due to HIV but, to ensure that TB mortality is reduced by 50% or more by 2015, HIV-infected TB patients should be provided with antiretroviral therapy in addition to the recommended treatment for TB.

Effectiveness of cotrimoxazole prophylaxis on mortality in adults with tuberculosis in rural South Africa

BACKGROUND

Adults with dual tuberculosis (TB) and HIV infection have a poor outcome. Studies in West Africa suggest that cotrimoxazole prophylaxis may reduce this mortality.

OBJECTIVE

To evaluate the effectiveness of cotrimoxazole in reducing mortality in adults with active TB, irrespective of HIV status, in a high prevalence setting.

DESIGN

Cohort study using historical controls.

METHODS

Adults treated for TB between 1998 and 2000 were traced and vital status at 6 months ascertained (2004: control group). All adults starting treatment for TB between June 2001 and June 2002 were offered cotrimoxazole prophylaxis 960 mg once daily for 6 months during TB treatment irrespective of HIV status (1321: intervention group). Mortality, adverse reactions and adherence were compared between intervention and control groups.

RESULTS

HIV seroprevalence in patients with TB at the start of the intervention was estimated to be 78%. Mortality at 6 months was 29% lower in the group given cotrimoxazole than in the control group. The number needed to treat to prevent one death during the period of TB treatment was 24. The benefit was seen across all types of TB but was only evident in new patients; patients being retreated had similar outcomes in both groups. Adverse events were infrequent and minor, with only two participants having treatment stopped for this reason.

CONCLUSION

Cotrimoxazole prophylaxis for all adults with TB, irrespective of HIV status, in an area of high HIV seroprevalence may be a feasible, safe and effective way to reduce mortality for the duration of treatment.

Transmission of tuberculosis from smear negative patients: a molecular epidemiology study

BACKGROUND

While smear positive patients with tuberculosis (TB) are considered more infectious than smear negative patients, the latter can also transmit TB.

METHODS

In a molecular epidemiology study of 791 patients in the Greater Vancouver regional district, the number of episodes of TB transmission from two groups of smear negative clustered patients by RFLP (assumed to be involved in recent transmission) was estimated after assessing for potential bias. Group 1 (n = 79) included patients with pulmonary TB or pulmonary + extrapulmonary disease (PTB or PTB+EPTB); group 2 (n = 129) included all patients in group 1 + extrapulmonary cases alone.

RESULTS

In the total sample the mean (SD) age was 51 (21) years, 54.3% were male, and 17.0% of patients were clustered. Compared with smear negative patients, smear positive patients were more likely to be in a cluster (OR = 2.0, 95% CI 1.1 to 3.6) and to have had a history of ethanol abuse (OR = 2.7, 95% CI 1.0 to 6.7), diabetes mellitus (OR = 2.8, 95% CI 1.1 to 7.0), injection drug use (OR = 3.1, 95% CI 1.1 to 8.3), and to have had a previous hospital admission (OR = 8.5, 95% CI 5.1 to 14.0). The proportion of episodes of transmission from smear negative clustered patients ranged from 17.3% to 22.2% in group 1 and from 25% to 41% in group 2.

CONCLUSION

In Greater Vancouver, smear negative cases appear responsible for at least one sixth of culture positive episodes of TB transmission.

Prevalence of HIV-1 infection among patients with leprosy and pulmonary tuberculosis in a semi-arid region, Nigeria

Much evidence exists on pulmonary tuberculosis (PTB) as a presenting feature of HIV infection or AIDS-related complex, while few reports exist of a direct association between HIV infection and leprosy. This study was carried out to see whether or not an association between leprosy and HIV infection existed, similar to that of PTB in the region of Maiduguri, Nigeria. Of 105 patients with leprosy, 11(10.5%) were positive for HIV antibody. Of 58 patients with suspected PTB, 11(19%) were positive for HIV antibody. Twenty-seven (47%) of the 58 had active PTB, with results of sputum smear and culture positive for mycobacterium, and six of these (22.2%) were also positive for HIV antibody. Odds ratios (OR) obtained by conditional logistic regression (matched) analysis were 3.52 (95%, CI 1.03-12.07) and 2.53 (95%, CI 1.04-6.15) for association between HIV-1 and PTB and leprosy, respectively. HIV infection was more prevalent among leprosy patients aged under 30 years, OR = 4.25 (95%, CI 1.25-14.42). The prevalence of HIV-1 infection was at borderline significance, higher in PTB and leprosy patients than in blood donors, Fisher's exact test (two-tailed) p = 0.07 and p = 0.05, respectively.

Evaluation of outpatients with suspected pulmonary tuberculosis in a high HIV prevalence setting in Ethiopia: clinical, diagnostic and epidemiological characteristics

In a setting with a high prevalence of HIV we studied (i) the prevalence of pulmonary tuberculosis (PTB) and HIV; (ii) clinical and epidemiological characteristics of PTB; and (iii) the usefulness of standard procedures for diagnosing PTB. Of 509 consecutive outpatients evaluated on clinical suspicion of PTB in Addis Ababa, 33.0% were culture-verified as having PTB. PTB patients, non-TB patients and controls were HIV-1-positive in 57.1%, 38.5% and 8.3% of cases, respectively. Predictors for culture-verified PTB were age < 25 y, male gender and the presence of HIV and fever, whereas profound weight loss indicated HIV infection. Diagnosis of PTB based on clinical symptoms, sputum microscopy for acid-fast bacilli and chest radiography was sensitive (86.7%) but unspecific (64.1%). In HIV-positive patients both sensitivity and specificity were significantly lower (p < 0.05). HIV-related pulmonary infections are often misinterpreted as smear-negative PTB. HIV screening is therefore warranted not only in cases of verified TB but also as part of the diagnostic work-up in patients with respiratory symptoms suggestive of PTB. Also, increased awareness of, and improved diagnostic tools for, HIV-related pulmonary infections other than PTB are required, together with algorithms for patients with suspected PTB.

Cotrimoxazole prophylaxis for opportunistic infections in adults with HIV

BACKGROUND

The prevention and early treatment of infections are the mainstay of the medical management of the majority of people with HIV infection, who live in low income countries without access to antiretroviral drugs. Cotrimoxazole is cheap and effective against a wide range of organisms. However, routine prophylactic treatment is difficult to deliver in low-resource settings, and could also lead to increased resistance to the drug.

OBJECTIVES

To assess the effects of routinely administered cotrimoxazole on death and illness episodes in HIV infected adults.

SEARCH STRATEGY

We searched the Cochrane HIV/AIDS Group register, the Cochrane Controlled Trials Register, MEDLINE, LILACS, AIDSLINE, AIDSTRIALS and AIDSDRUGS databases, and proceedings and abstracts from AIDS and tuberculosis (TB) conferences (search date July 2001). We checked reference lists for trials and other pertinent articles, and contacted pharmaceutical companies and experts in the field.

SELECTION CRITERIA

Randomised or quasi randomised trials comparing routinely administered cotrimoxazole versus placebo or no treatment in adults (age greater than 13 years).

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial eligibility and quality, and extracted data. Where data were incomplete or unclear trial authors were contacted for further details.

MAIN RESULTS

Four trials involving 1476 people were identified. Three trials (1416 people) studied heterosexual men and women in West Africa. A fourth trial was of homosexual men on chemotherapy for Kaposi's sarcoma, in the United States. Meta-analysis of the three African trials showed a significant beneficial effect of cotrimoxazole for death: relative risk 0.69 (95% confidence interval 0.55 to 0.87); for morbid events: 0.76 (0.64 to 0.9); and for hospitalisation: 0.66 (0.48 to 0.92). There was no significantly greater risk of adverse effects: relative risk 1.28 (0.47 to 3.51). Effects were similar in people with early and advanced HIV disease. Insufficient evidence was found on effects in areas with higher bacterial resistance or in people on antiretroviral therapy.

REVIEWER'S CONCLUSIONS

In the trials included in the review, cotrimoxazole prophylaxis had a beneficial effect in preventing death and illness episodes in adults with both early and advanced HIV disease. However, the wider applicability of these findings is unclear, in particular to areas with higher background bacterial resistance to cotrimoxazole. Further trials would be required in differing settings to widen applicability.

Clinical features of tuberculosis among adults in sub-Saharan Africa in the 21st century

Although tuberculosis was unknown in sub-Saharan Africa before the 19th century, rapid spread of infections due to Mycobacterium tuberculosis occurred during the 20th century and could be found in up to 50% of the adult population by the 1950s. Owing to changes in age structure, rapid urbanization associated with overcrowding living conditions, increasing poverty and the HIV epidemic a 300-400% increase in tuberculosis cases and deaths has been reported from sub-Saharan Africa. Persons dually infected with HIV and tuberculosis may have active tuberculosis with typical or atypical clinical features and/or involving multiple organ systems. In addition, mycobacteraemia associated with non-specific clinical features is common among HIV-infected persons, especially if they are severely immunocompromised. Because of the atypical clinical features these patients are easily misdiagnosed and are therefore likely to die from what is otherwise a curable illness. Consequently there is a need to better characterize the clinical features of all forms of tuberculosis, especially in the presence of HIV infection.

Risk factors for human immunodeficiency virus infection in Ethiopian children with tuberculosis

BACKGROUND

Separate risk factors for HIV infection and for tuberculosis (TB) are well-studied, but it is unclear whether these risk factors still apply in the new epidemiologic situation of dual infection. This study examines risk factors associated with seropositivity for HIV in Ethiopian children with clinical TB.

METHODS

A prospective, controlled study of children with TB diagnosed in Addis Ababa from December 11, 1995, to January 28, 1997, in which HIV-positive children were compared with HIV-negative children with regard to sociodemographic background, previous medical history and vaccination.

RESULTS

HIV prevalence among children with clinical TB was 11.2%. High educational status of mothers, low age, loss of one or two parents and earlier Calmette-Guérin bacillus (BCG) vaccination of the child were factors independently related to HIV infection.

CONCLUSION

Factors associated with HIV infection among children with clinical TB include higher education of parents, higher income and better living conditions. The HIV epidemic might thus modify traditional risk factors for tuberculosis. It might also decrease the overall effect of BCG vaccination given that BCG did not provide protection in children infected with HIV. An expected increase of dually infected children who are younger, more in need of hospitalization and often lacking one or both parents will put an additional burden on the Ethiopian health care system.

Identifying pulmonary tuberculosis in patients with negative sputum smear results

BACKGROUND

Clinicians need to decide whether to begin empiric therapy for patients who are suspected of having tuberculosis (TB) but have negative sputum smear results. Culture results may take weeks, and delaying treatment may allow further transmission of disease.

STUDY OBJECTIVE

To identify the clinical, demographic, and radiographic characteristics that identify smear-negative patients who have TB, and to create a TB prediction rule.

DESIGN

Retrospective chart review.

SETTING

University-affiliated public hospital in San Francisco, CA, between 1993 and 1998.

PATIENTS

Forty-seven patients with TB and 141 control patients who were hospitalized with a suspicion of pulmonary TB; all had negative sputum smear results.

MEASUREMENTS AND RESULTS

Demographic, clinical, and radiographic variables were determined by chart review. In multivariate analysis, a positive tuberculin skin test result (odds ratio [OR], 4.8; 95% confidence interval [CI], 2.0 to 11.9) was independently associated with an increased risk of a positive TB culture finding. A radiographic pattern not typical of pulmonary tuberculosis (OR, 0.3; 95% CI, 0.1 to 0.7) and expectoration with cough (OR, 0.3; 95% CI, 0.1 to 0.6) were predictive of a decreased risk. An interaction between HIV seropositivity and mediastinal lymphadenopathy on the chest radiograph was also associated with a positive TB culture result (OR, 7.2; 95% CI, 1.4 to 36.0). The TB prediction score (TPS) was created with widely ranging likelihood ratios that could affect the posterior probability of TB by 30-fold.

CONCLUSION

The TPS put into context with the overall prevalence of TB in a given area may help clinicians decide if a patient with negative sputum smear results should start empiric antituberculous therapy or wait for culture results. These results need prospective validation.

Role of cerebrospinal fluid shunting for human immunodeficiency virus-positive patients with tuberculous meningitis and hydrocephalus

OBJECTIVE

Tuberculous meningitis (TBM) and its complications continue to have devastating neurological consequences for patients. Budgetary constraints, especially in developing countries, have made it necessary to select patients for shunting who are likely to experience good recoveries. To date, the value of cerebrospinal fluid shunting for human immunodeficiency virus (HIV)-positive patients with TBM has not been clearly established.

METHODS

Thirty patients with TBM and hydrocephalus were prospectively evaluated. Coincidentally, one-half of the patients were HIV-positive. All patients underwent uniform treatment, including ventriculoperitoneal shunt placement and antituberculosis treatment. CD4 counts were measured for all patients. Outcomes were assessed at 1 month.

RESULTS

No complications related to shunt insertion were noted. The HIV-positive group fared poorly (death, 66.7%; poor outcome, 64.7%), compared with the HIV-negative group (death, 26.7%; poor outcome, 30.8%). Despite cerebrospinal fluid shunting, no patient in the HIV-positive group experienced a good recovery (Glasgow Outcome Scale score of 5). This is in contrast to the six patients (40%) in the HIV-negative group who, with the same treatment, experienced good recoveries (Glasgow Outcome Scale scores of 5) at discharge (P<0.14). No patient (either HIV-positive or HIV-negative) who presented in TBM Grade 4 survived, whereas no HIV-positive patient who presented in TBM Grade 3 survived. A significant relationship was noted between CD4 counts and patient outcomes (P<0.031).

CONCLUSION

In the absence of obvious clinical benefit, HIV-positive patients with TBM should undergo a trial of ventricular or lumbar cerebrospinal fluid drainage, and only those who exhibit significant neurological improvement should proceed to shunt surgery.

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.

Efficacy of trimethoprim-sulphamethoxazole prophylaxis to decrease morbidity and mortality in HIV-1-infected patients with tuberculosis in Abidjan, Côte d'Ivoire: a randomised controlled trial

BACKGROUND

There is a high incidence of opportunistic infection among HIV-1-infected patients with tuberculosis in Africa and, consequently, high mortality. We assessed the safety and efficacy of trimethoprim-sulphamethoxazole 800 mg/160 mg (co-trimoxazole) prophylaxis in prevention of such infections and in decrease of morbidity and mortality.

METHODS

Between October, 1995, and April, 1998, we enrolled 771 HIV-1 seropositive and HIV-1 and HIV-2 dually seroreactive patients who had sputum-smear-positive pulmonary tuberculosis (median age 32 years [range 18-64], median CD4-cell count 317 cells/microL) attending Abidjan's four largest outpatient tuberculosis treatment centres. Patients were randomly assigned one daily tablet of co-trimoxazole (n=386) or placebo (n=385) 1 month after the start of a standard 6-month tuberculosis regimen. We assessed adherence to study drug and tolerance monthly for 5 months and every 3 months thereafter, as well as rates of admission to hospital.

FINDINGS

Rates of laboratory and clinical adverse events were similar in the two groups. 51 patients in the co-trimoxazole group (13.8/100 person-years) and 86 in the placebo group (25.4/100 person-years) died (decrease In risk 46% [95% CI 23-62], p<0.001). 29 patients on co-trimoxazole (8.2/100 person-years) and 47 on placebo (15.0/100 person-years) were admitted to hospital at least once after randomisation (decrease 43% [10-64]), p=0.02). There were significantly fewer admissions for septicaemia and enteritis in the co-trimoxazole group than in the placebo group.

INTERPRETATION

In HIV-1-infected patients with tuberculosis, daily co-trimoxazole prophylaxis was well tolerated and significantly decreased mortality and hospital admission rates. Our findings may have important implications for improvement of clinical care for such patients in Africa.

Chest imaging in AIDS

A review of imaging in the acquired immune deficiency syndrome (AIDS) is presented. The imaging features can be conveniently categorized according to whether the presenting complications are infective (bacterial, protozoal, or fungal), bronchiectasis, neoplastic (Kaposi's sarcoma, AIDS-related lymphoma, or lymphoproliferative disease), or a miscellaneous group (non-specific interstitial pneumonitis, persistent generalized lymphadenopathy, or bronchogenic carcinoma).

Evidence of stable HIV seroprevalences in selected populations in the Democratic Republic of the Congo

OBJECTIVE

To determine current data on HIV infection and to document changes and trends of HIV seroprevalence in selected populations over time in the Democratic Republic of the Congo (DRC; former Zaïre).

METHODS

In February 1997, a large serosurvey was conducted on selected population groups from Kinshasa (capital city), Mbuji-May (southeast) and Bwamanda (northwest). Samples obtained from pregnant women, tuberculosis patients, commercial sex workers, blood donors and sexually transmitted disease patients were screened for the presence of HIV antibodies by a rapid assay and a commercial enzyme-linked immunosorbent assay. All reactive specimens were confirmed and discriminated by a line immunoassay, and were further tested for the presence of HIV-1 group O antibodies. Our results were compared to data reported in previous studies in Kinshasa.

RESULTS

Of a total 1970 samples collected, 219 (11.1%) were HIV-1-reactive and seven (0.3%) were dually reactive to HIV-1 and HIV-2. No case of HIV-1 group O or HIV-2 infection was diagnosed. HIV seroprevalence in pregnant women was 3.1% (16 out of 511), 6.3% (19 out of 300) and 1.5% (one out of 65) in Kinshasa, Mbuji-Mayi, and Bwamanda, respectively. HIV seroprevalence in tuberculosis patients was 26% (52 out of 200), 28% (17 out of 60), and 35.3% (29 out of 83), respectively. HIV seroprevalence among blood donors was 3.1% in Kinshasa and 2.8% in Mbuji-Mayi. Compared with data from previous studies performed in Kinshasa, no substantial change in HIV infection rates was observed among the selected population groups.

CONCLUSIONS

Our results show that HIV prevalence rates have remained relatively unchanged in selected populations despite the political instability and poor environment observed since 1991 in DRC. It also shows the presence, still at very low rate, of dual HIV-1/HIV-2 seropositivity and a growing problem of HIV infection in rural areas. In contrast to other Central African countries, no HIV-1 group O infections were detected in DRC.

HIV-testing study of immigrants with pulmonary tuberculosis

The increasing prevalence of tuberculosis (TB) and human immunodeficiency virus (HIV), particularly in Africa and Asia, led us to investigate the prevalence of HIV infection in immigrants with pulmonary TB at the time of arrival in the UK. We performed anonymous HIV testing of stored sera from 39/65 immigrants referred to our unit between January 1991 and December 1994, who had culture-positive pulmonary TB. None of the 39 patients tested was positive for either HIV-1 or HIV-2, and the characteristics of the 26 patients for whom no serum was available were similar to those of the tested group. Despite the need to consider concomitant HIV infection in any patient with TB, particularly those from an area of HIV endemnicity, the present data do not suggest that recently arrived refugees, asylum seekers, immigrants or long-term visitors to the UK constitute a group in whom dual infection of HIV and Mycobacterium tuberculosis is common.

Radiological features of pulmonary tuberculosis in 963 HIV-infected adults at three Central African Hospitals

Tuberculosis is one of the most important infectious complications in human immunodeficiency virus (HIV)-infected individuals in sub-Saharan Africa. In this radiological study, we detail the chest radiographic findings of Zairean and Zambian adults with a diagnosis of AIDS and tuberculosis as seen at three Central African Hospitals. Between 1992 and 1995, consecutive chest radiographs of 963 HIV-infected adults aged between 16 years and 56 years with microbiologically confirmed tuberculosis (TB) were reviewed: (1) 362 adults from Sendwe General Hospital, Lubumbashi, Zaire, (2) 175 from Mama Yemo Hospital, Kinshasa, Zaire, and (3) 426 adults from The University Teaching Hospital (UTH), Lusaka, Zambia. During the same period consecutive chest radiographs from 1000 age-matched HIV-negative adults with tuberculosis were collected for comparative purposes. Comparison of the two groups showed that the HIV-infected group of patients with tuberculosis had a significantly higher proportion of lymphadenopathy (26% vs 13%; P = 0.001), pleural effusions (16% vs 6.8%; P = 0.001), miliary shadowing (9.8% vs 5%; P = 0.001), an interstitial pattern (12% vs 7%; P = 0.01) and consolidation (10% vs 3%; P = 0.001). There was significantly less cavitation (33% vs 78%; P = 0.001) and atelectasis (12% vs 24%; P = 0.001) seen in the HIV-positive group compared to the HIV-negative group of patients. These patterns of radiographic changes were consistently seen across all three hospital sites. The radiographic appearances in HIV-infected individuals with TB is discussed.

Issues in the management of contacts of patients with active pulmonary tuberculosis

The evidence regarding the transmission of tuberculosis and risk of infection and disease in several specific clinical situations has been reviewed. There is considerable epidemiologic evidence that contagiousness is not an all-or-nothing phenomenon and is affected by several factors, only one of which is the bacteriologic status of the patient's sputum. Although untreated smear negative, culture positive patients are less contagious on average, they still may transmit infection to their close and casual contacts. Compared with contacts with tuberculin conversion, persons who are already tuberculin positive have much lower risk of developing active tuberculosis after exposure, and persons with prior BCG vaccination are at somewhat lower risk. Preventive therapy will be of less benefit, but should still be recommended for contacts who are heavily exposed or are immune compromised. Epidemiologic studies using RFLP techniques could provide more precise answers to the questions in this review.

Pneumonia and tuberculosis in pregnancy

Antepartum pneumonia requires prompt evaluation and empiric antimicrobial therapy. The choice of antimicrobial therapy depends on maternal risk factors, symptoms, and clinical presentation. Although laboratory studies such as culture and serology should be obtained, they may not always yield a specific etiologic agent. However, prompt empiric treatment and supportive care should lead to good maternal and fetal outcomes. Similarly, in most cases, proper diagnosis and treatment of TB during pregnancy yield good maternal and fetal outcomes. TB screening is essential for the growing population of individuals with HIV infection and recent immigrants from areas where tuberculosis is endemic.

Impact of human immunodeficiency virus infection on abdominal tuberculosis in western India

We studied the seroprevalence of human immunodeficiency virus infection in patients with pulmonary tuberculosis and abdominal tuberculosis. We also assessed the clinical characteristics, risk factors, tuberculin status, site, and response to therapy of abdominal tuberculosis in human immunodeficiency virus (HIV)-seropositive and HIV-seronegative patients. Volunteer blood donors (n = 8,395), patients with pulmonary tuberculosis (n = 387), and patients with abdominal tuberculosis (n = 108) were screened for HIV 1 and/or HIV 2 by enzyme-linked immunosorbent assay (ELISA; Torrent, India) and positivity reconfirmed by a repeat ELISA and Western blot test. The HIV seroprevalence in the abdominal tuberculosis patients (16.6%) was significantly higher compared with those with pulmonary tuberculosis (6.9%, p < 0.05) and volunteer blood donors (1.4%, p < 0.01). Absolute lymphocyte counts did not differ between the HIV-seropositive and HIV-seronegative patients (2,044.94 +/- 830 vs 2,261.34 +/- 805/mm3, p = NS). The Mantoux reaction was larger in the HIV-seronegative group as compared with the HIV-seropositive group (14.8 mm vs. 9.5 mm, p < 0.05). Tuberculosis patients responded well to conventional antituberculosis drugs in standard doses regardless of their HIV status.

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.

Pneumocystis carinii and cytomegalovirus infections in severely ill, HIV-infected African infants

Unlike in the industrialized world, in which Pneumocystis carinii and cytomegalovirus (CMV) are major respiratory opportunistic organisms, the causes of severe pneumonia, which accounts for much of the mortality in HIV-infected infants in developing countries, are not known, although tuberculosis has been associated with HIV in adults. We report on post-mortem lung and liver biopsies obtained soon after death from 36 HIV-infected infants and 36 HIV-uninfected matched controls who had been admitted with severe pneumonia to an ICU. Nineteen of the HIV-infected infants were classified by WHO criteria as having AIDS and 17 'symptomatic HIV'. P. carinii and CMV were detected significantly more frequently in lung tissue from the AIDS patients (14 of 18 samples tested, p < 0.01; 14 of 18 samples tested, p < 0.01, respectively) as compared with matched controls. P. carinii was detected in two of 13 lung biopsies from symptomatic HIV infants, but in none of the controls. Lung tissue obtained from AIDS patients had P. carinii and CMV more frequently (p < 0.01, p < 0.01, respectively) than that from symptomatic HIV patients. CMV was also detected in excess in liver tissue from AIDS infants (five of 18 samples) as compared with that from symptomatic HIV (0 of 16; p = 0.03) and matched controls (two of 34; p = 0.04). Ante-mortem investigations revealed more CMV infections in AIDS patients (four of 19) than in matched controls (0 of 36; p < 0.01). Tuberculosis was detected in post-mortem lung tissue from only one patient with symptomatic HIV infection. The finding that pathogens (P. carinii, CMV) most frequently detected in seriously ill African infants with HIV/AIDS are similar to those in their counterparts from industrialized countries has implications for improved management in the former.

Oral tuberculosis

Tuberculous lesions of the oral cavity have become so infrequent that it is virtually a forgotten disease entity and may pose a diagnostic problem. Fifteen patients with conditions that were histologically diagnosed as oral tuberculosis were reviewed. All were men ranging in age from 29 to 78 years. The most common clinical presentation was odynophagia with a duration from less than 1 week to several years. The most frequently affected sites were the tongue base and gingiva. The oral lesions took the form of an irregular ulceration or a discrete granular mass. Mandibular bone destruction was evident in two patients. Two patients had a fever, and four had cervical lymphadenopathy. Eight cases were clinically suspicious for malignancy before biopsy. Only four patients had a history of tuberculosis, but 14 of the 15 patients were later found to have active pulmonary tuberculosis. Acid-fast bacilli were demonstrated in all patients. Tuberculosis should be considered in patients with an inflamed ulcer lesion. A biopsy specimen for histologic study, acid-fast stains, and cultures should be obtained for confirmation and differential diagnosis with other conditions. If a tuberculous lesion is suspected, a chest radiograph is indicated to investigate the possibility of pulmonary involvement.

Cost-effectiveness and total costs of three alternative strategies for the prevention and management of severe skin reactions attributable to thiacetazone in the treatment of Human Immunodeficiency Virus positive patients with tuberculosis in Kenya

SETTING

Severe skin reactions due to thiacetazone (T) in Human Immunodeficiency Virus (HIV) positive tuberculosis patients have been reported in several publications, one of them from Kenya. However, the abandoning of T may not be feasible in Kenya as this may increase the cost of drugs by about three-fold per regimen.

OBJECTIVE

To compare the cost-effectiveness and total cost of three strategies in which T is replaced with ethambutol (E).

DESIGN

Three strategies are compared with a baseline strategy in which T is not replaced. The indicator for cost-effectiveness is the cost-per-averted-death attributable to T.

RESULTS

Education of patients on the possibility of side-effects and replacement of T with E is the most cost-effective strategy at HIV prevalence rates of 1-90%. Abandonment of T and replacement with E is the most cost-effective at over 90% HIV prevalence.

CONCLUSION

In Kenya, education of patients on the possibility of skin reactions should be preferred at low range HIV prevalence rates. Routine HIV testing would be the most attractive strategy in the middle range, and total replacement of T with E is to be preferred in the higher range of HIV prevalence.

Predictive markers of survival in HIV-seropositive and HIV-seronegative Tanzanian patients with extrapulmonary tuberculosis

SETTING

Prediction of survival in Tanzanian patients with extrapulmonary tuberculosis (TB).

OBJECTIVE

To evaluate the prognostic value of clinical and laboratory parameters on survival in human immunodeficiency virus (HIV) seropositive and HIV seronegative patients with extrapulmonary TB.

DESIGN

Over an 8-month period 192 consecutive patients with extrapulmonary TB, admitted to a major referral centre in Tanzania, were enrolled in the study. Their symptoms, signs and PPD skin test were noted. Their sera were tested for HIV and analyzed for beta-2-microglobulin content. Univariate risk factors for 12 months' survival after the start of anti-TB chemotherapy were entered into a stepwise Cox regression model. Survival probabilities were estimated according to the number of risk factors.

RESULTS

Of the 192 patients 126 (65%) were HIV-infected, and 29.7% had disseminated TB. Thirty-five patients, of whom 24 (68.6%) were HIV-positive, withdrew from the study immediately after hospital discharge. For survival analysis 157 patients remained. Within 12 months' follow-up after initiation of anti-TB therapy, the case fatality rate of the 102HHIV-infected patients was 22% and of the 55 HIV seronegative patients 2% (P < 0.001). In the HIV seropositive patients the following independent risk factors were significantly associated with a decreased probability of survival: peripheral lymphadenopathy (Hazard Rate Ratio (HRR) 5.2, 95% Confidence Interval [CI] 1. 7-16.2), a decreased activity score (bedridden > 50%/day (HRR 4.5, 95% CI 1.7-11.7), lymphopenia of < 1000/microL (HRR 4.4, 95% CI 1.7-11.8), and mycobacteraemia (HRR 4.0, 95% CI 1.2-13-.1). An anergic PPD skin test reaction proved to be another independent risk factor when the analysis was performed on 89 patients with available Mantoux test results. In the HIV seropositive patients, the 12 months' survival probabilities were 93%, 86%, 54% and 0% for presence of 0, 1, 2, and > 2 risk factors respectively.

CONCLUSION

Estimation of survival probabilities in patients with extrapulmonary TB may be possible without performing CD4 cell counts.

Clinical features of HIV seropositive and HIV seronegative patients with tuberculous lymphadenitis in Dar es Salaam

SETTING

The medical wards of a referral hospital in Dar es Salaam, Tanzania.

OBJECTIVE

To investigate the impact of HIV infection on clinical features in tuberculous lymphadenitis.

DESIGN

A prospective clinical study of HIV seropositive and HIV seronegative patients with lymphadenopathy.

RESULTS

Of 128 patients with peripheral lymphadenopathy, 24 had no tuberculosis (TB) and in 10 patients TB was found only in other organs. The remaining 94 patients, of whom 76% were HIV seropositive, formed our study population. TB lymphadenitis was considered proven in 89 and probable in 5 patients. Disseminated TB (both TB adenitis and TB in other organs) was diagnosed more often in HIV seropositive than in HIV seronegative patients (52% versus 26%, P < 0.03). 59% of the 71 HIV-infected patients compared to only 4% of the 23 patients without HIV infection were over 30 years of age (P < 0.02). The following clinical features were significantly associated with HIV infection: dyspnoea, respiratory rate > 20/min, low motility score (bedridden), neurological abnormalities, hepatomegaly, splenomegaly, lymph node size < 2.5 cm, negative PPD skin test, lymphopenia (< 1000/cm3) and presence of pleural fluid.

CONCLUSION

Co-infection with HIV influences several clinical and laboratory features in patients with tuberculous lymphadenitis.