Treatment outcomes and factors associated with mortality among individuals with both TB and HIV in the antiretroviral era in Thailand

OBJECTIVE

This study aimed to compare treatment outcomes and factors associated with mortality in HIV-1-positive and HIV-1-negative individuals.

METHODS

We conducted a cohort study between July 2008 and December 2016. Logistic regression was used to determine factors associated with outcomes and death after tuberculosis (TB) treatment.

RESULTS

A total of 996 individuals with TB, 228 (22.9%) with HIV-1 co-infection and 770 (77.1%) who were HIV-1 negative were reviewed. The overall treatment success rate was 74.3%. The HIV-1-negative individuals with TB had significantly higher treatment success rates (77.2% vs 64.5%, P < 0.001). Using logistic regression analysis, age >50 years (adjusted odds ratio [aOR] 3.89, 95% confidence interval [CI] 2.24-6.76; P < 0.001), body weight ≤45 kg (aOR 2.19, 95% CI 1.14-4.19; P = 0.02) and HIV-1-positive status (aOR 3.31, 95% CI 1.84-5.91; P < 0.001) were independently associated with death during TB treatment. Among HIV-1-positive individuals, not undergoing antiretroviral therapy (ART), having diabetes and a CD4 T cell count of <50 cells/mm3 were significantly associated with death.

CONCLUSION

Individuals who had both TB and HIV-1 in Thailand had lower TB treatment success and higher mortality rates compared with individuals with TB without HIV-1. Strategies to improve ART uptake and to reduce risk of developing active TB among individuals with advanced HIV-1 infection should be scaled up.

Real-Life Clinical Practice of Using the Xpert MTB/RIF Assay in Thailand

Background

Delayed diagnosis of tuberculosis (TB) and drug-resistant TB are major challenges of TB control in Thailand. This study assessed the practicality of the Xpert MTB/RIF assay in a real-life setting with high prevalence of human immunodeficiency virus (HIV) infection and pulmonary tuberculosis (PTB).

Methods

This prospective study was conducted at 3 large tertiary care hospitals. Patients who had suspected PTB were enrolled into the study. Expectorated sputum samples were sent for staining, mycobacterial culture, and Xpert MTB/RIF.

Results

Four hundred ninety-four patients were enrolled. From 355 cases with final diagnosis of PTB, 263 (71.8%) had definite diagnosis and 92 cases had probable diagnosis. Among TB culture-positive cases, Xpert MTB/RIF had 100% and 81% sensitivity in sputum smear-positive and smear-negative groups, respectively. The specificity was 95.7%. The sensitivity and positive predictive value of Xpert MTB/RIF in culture-negative but clinically diagnosed PTB was 37.8% and 83.8%, respectively. Centrifugation was required in 59% cases with scanty sputum. Five cases were false-positive by Xpert MTB/RIF in patients with nontuberculous mycobacteria, old PTB scar, and immune reconstitution syndrome. Discordant rifampicin susceptibility results of Xpert MTB/RIF and mycobacteria growth indicator tube (MGIT) were confirmed by using rpoB gene sequencing, which raised the sensitivity of Xpert MTB/RIF in detecting rifampicin resistance to 93.8%.

Conclusions

Xpert MTB/RIF is an effective tool in diagnosing PTB but will be more cost-effective for sputum-negative patients and in settings with high prevalence of rifampicin resistance. Early diagnosis of TB results in early treatment and implementation of strategies to limit spreading of TB. Sputum centrifugation may increase the yield of Xpert MTB/RIF.

Drug resistance among new smear-positive pulmonary tuberculosis cases in Thailand

SETTING

A 1200-bed hospital in Bangkok, Thailand.

OBJECTIVE

To describe pre-treatment drug susceptibility patterns and determine factors predicting drug resistance in new sputum-smear positive tuberculosis (TB) patients in Thailand.

DESIGN

In a retrospective cohort study from October 2007 to September 2010, clinical data on all new sputum-smear positive pulmonary TB (PTB) patients were reviewed. The pre-treatment drug susceptibility patterns and statistically significant differences in variables between groups of patients were described.

RESULTS

A total of 769 new smear-positive PTB patients were included in the study. Overall rates of pre-treatment isoniazid resistance and multidrug-resistant TB were respectively 11.8% and 2.5%. TB patients co-infected with the human immunodeficiency virus (HIV) had a four times greater risk of pre-treatment drug resistance than non-HIV-infected patients. No other groups of patients that needed to be prioritised for drug susceptibility testing (DST) were identified.

CONCLUSION

Groups of patients to be prioritised for DST other than those with HIV infection could not be identified.

Factors predicting sputum smear conversion and treatment outcomes in new smear-positive pulmonary tuberculosis

BACKGROUND

Epidemiological studies indicated that the proportion of TB patients who remained smear-positive after two months of treatment could be greater than 20%. The lack of smear conversion in the second month of treatment was one of the predictors of treatment failure and relapse.

OBJECTIVE

To determine factors associated with the persisting positive smear after two months of treatment and its value in predicting treatment failure.

MATERIAL AND METHOD

A 3-year retrospective cohort study was conducted in a 1,200-bed government hospital in Thailand New smear-positive tuberculosis patients who had pretreatment drug susceptibility test, the result of 2-month sputum smear and treatment outcomes were selected. The pretreatment drug susceptibility pattern and statistically differences on variables between groups of patients were described

RESULTS

Three hundred fifty six patients were included in the present study. The level of pretreatment isoniazid resistance and multi-drug resistance were 13.8% and 3.1% respectively. Factors associated with the 2-month positive smear were male sex, high initial sputum acid-fast bacilli grades, and cavitary diseases. The presence of human immuno-deficiency virus infection, drug resistance and the 2-month positive smear were significantly associated with treatment failure.

CONCLUSION

Male sex, high initial sputum acid-fast bacilli grades, and cavitary diseases were factors associated with the 2-month positive smear and increasing risk of treatment failure.

Sarcoidosis mimics lepromatous leprosy: a case report

A 34-year-old Thai man presented with a two years history of progressively enlarged lepromatous leprosy like nodules and plaques on his back, chest, and scalp. Skin biopsy showed diffuse nonnecrotizing granulomatous inflammation with numerous multinucleated giant cells, lymphocytes, and plasma cells infiltration. The missed diagnosis of leprosy was made and was treated with antilepromatous drugs for one year. After repeated skin biopsy, the diagnosis was compatible with sarcoidosis. He was treated with prednisolone 40 mg per day for two weeks. The lesions gradually decreased in size and were controlled with prednisolone 10 mg per day.

Medical characteristics and tuberculosis treatment outcomes in an urban tertiary hospital, Thailand

The purpose of this study was to describe medical characteristics and assess treatment outcomes at a respiratory clinic, tertiary hospital, Bangkok, Thailand. One hundred seventy-seven patients diagnosed as having any type of TB and having taken anti-TB drugs for one month were included in the study. The patients were interviewed the end of the first month and their medical files were reviewed at the end of treatment to obtained the treatment outcome. Descriptive statistics and chi-square test were used in the data analyses. Of the total of 177 patients, 33.3% were new smear-positive, 19.2% were new smear-negative, 18.1% were extra-pulmonary TB, and 29.4% were other. The prevalence of TB/HIV co-infection was 33% (18 of 54). Resistance to at least one anti-TB drug was 31.6% (6 of 19). Due to high treatment default rates, treatment completion rates were low, 64.4% in new smear-positives, 61.8% in new smear-negatives, 71.9% in extra-pulmonary TB, and 46.2% in other. Treatment default rates significantly differed among the four types of TB (chi2 = 8.3, p = .04). The findings indicate a high proportion of extra-pulmonary TB, high prevalence of TB/HIV coinfection, and low treatment completion in urban TB patients at the tertiary hospital. Interventions are needed to integrate the strengths of the tertiary hospital regarding the availability of chest specialists and advance diagnostic tools into the other levels of health service to improve treatment outcomes in urban populations.

Respiratory complication of tsunami victims in Phuket and Phang-Nga

In the present report the authors describe the clinical and laboratory findings of 26 tsunami victims admitted to the Phuket and the Takua Pa Hospital. Patients were classified into 4 groups of severity. class 1, baseline examination negative (n = 1); class 2, baseline examination positive but mechanical ventilation not needed on admission (n = 15); class 3, mechanical ventilation required on admission (n = 9); class 4, cardiopulmonary arrest (n = 1). On admission, 21/23 patients had fever of > 37.5 C. 3/10 patients had hypernatremia and 7/10 cases had metabolic acidosis. The radiological manifestation varied from focal disease to diffuse infiltrations, either reticulonodular or patchy lesions. There were 3 clinical courses among diffuse diseases: 1) diffuse infiltrations and progression 3 cases 2) diffuse infiltration, early regression followed by progression 2 cases 3) diffuse infiltration and steady regression 5 cases. Late complications comprised of pneumothorax/pneumomediastinum (n = 5) and bacterial pneumonia (n = 18). The authors got culture data in 9 patients, most of them were infected with aerobic gram -ve bacteria and 2 of them were B. pseudomallei. The prognosis in the tsunami related medical illness was favorable. Only 2 patients (7.7%) died in the present study.