Specific features of tuberculosis relapses in HIV infected patients

The growing number of people with advanced stages of HIV infection determines the specific course of newly diagnosed tuberculosis cases and relapses and accordingly, it requires a special approach to follow-up of such patients respective their dispensary group.

The objective of the study: to define the specific features of tuberculosis relapses in HIV patients.

Subjects and methods. 205 patients from Sverdlovsk Region were enrolled into a retrospective study. In all the patients, a relapse of respiratory tuberculosis was diagnosed (there were some single cases of combinations with other localizations of tuberculosis). Of them, 104 patients were diagnosed with HIV infection (Group I) and 101 patients were HIV negative (Group II). The groups were compatible respective the age and gender of the patients.

Results. HIV positive patients develop tuberculosis relapses earlier versus the HIV negative ones (in 31.5 ± 3.0 months and 55.1 ± 5.7 months respectively, p < 0.001).

When tuberculosis relapse was diagnosed, 49.0% (95% CI 47.1-77.7) of patients with HIV infection had their CD4 count < 200 cells/mcl, and most often such a low count was observed among the patients who had CD4 count of 200-349 cells/mcl at the moment when tuberculosis was cured. By the time when tuberculosis relapse was diagnosed among HIV positive patients, the level of antiretroviral therapy failure increased and made 31.7%, and there was a tendency (nearly statistically significant) towards the increase of the portion of ARVT courses lasting for less than 6 months.

In case of tuberculosis relapse, HIV positive patients developed disseminated and generalized tuberculosis more often versus HIV negative ones. The most frequent defects of dispensary follow up (dispensary follow-up group III) over the patients cured of tuberculosis, were the lower frequency of X-ray and bacteriological examinations and underestimation of clinical manifestations. It results in the postponed diagnostics of relapse long after its manifestations, less frequent diagnostics of relapses during planned examination, especially in HIV patients.

Probably, it is worth reconsidering the tactics of dispensary follow-up over HIV positive patients with TB history and following them up longer as active dispensary groups. The following could be the additional criteria for dispensary follow-up extension: CD4 count of 200 cells/mcl and lower and laboratory confirmed failing ARVT.

1. Bogorodskaya E.M., Аlekseeva V.M., Аgapova V.А. Impact of additional social support for new pulmonary tuberculosis patients on the economic efficiency of anti-tuberculosis chemotherapy. Zdravookhraneniye Rossiyskoy Federatsii, 2012, no. 2, pp. 21-23. (In Russ.)

2. VICH-infektsiya i SPID: natsionalnoe rukovodstvo. [HIV infection and AIDS: national guideline]. V.V. Pokrovsky, eds. Moscow, GEOTAR-Media Publ., 2013, pp. 144-160. (In Russ.)

3. Gashenko A.V. Sovershenstvovanie organizatsii rannego vyavleniya, dispansernogo nablyudeniya i monitoringa tuberkuleza, sochetannogo s VICH-infektsiey Avtoref. diss. kand. med. nauk. [Improvement of early detection, dispensary follow-up and monitoring of tuberculosis with concurrent HIV infection. Synopsis of Cand. Diss.]. Moscow, 2010, 24 p. (In Russ.)

4. Erokhin V.V., Kornilova Z.Kh., Аlekseeva L.P. Specifics of tuberculosis detection, clinical manifestations and treatment in HIV patients. Probl. Tub., 2005, no. 10, pp. 20-27. (In Russ.)

5. Zimina V.N. Sovershenstvovanie diagnostiki i effektivnost lecheniya tuberkuleza u bolnykh VICH-infektsiei pri razlichnoy stepeni immunosupressii. Avtoref. diss. dokt. med. nauk. [Diagnostics improvement and tuberculosis treatment efficiency of HIV patients with a different degree of immune suppression. Synopsis of Doct. Diss.]. Moscow, 2012, 44 p. (In Russ.)

6. Zimina V.N., Vasilyeva I.А., Batyrov F.А. et al. Specifics of the course and treatment efficiency of tuberculosis patients at the late stage of HIV infection. Probl. Tub., 2009, pp. 23-26. (In Russ.)

7. Kononchuk O.N., Kopylova I.F., Sibil K.V. Frequency and prevalence of the pulmonary tissue lesions in TB/HIV patients (results of X-ray examination). Materials of IXth Conference of Russian TB Doctors. Tuberculosis and Lung Diseases, 2011, no. 4, pp. 204-205. (In Russ.)

8. Kornilova Z.Kh., Lukonina I.V., Аlekseeva L.P. Tuberculosis with concurrent HIV infection. Tuberculosis and Lung Diseases, 2010, no. 3, pp. 3-8. (In Russ.)

9. Kravchenko А.V., Yurin O.G., Utekhin V.А. et al. Tuberculosis in HIV patients. Terapevticheskiy Arkhiv, 1996, no. 4, pp. 69-71. (In Russ.)

10. Panteleev A.M. Patogenez, klinika, diagnostika i lechenie tuberkuleza u bolnykh VICH-infektsiey. Diss. dokt. med. nauk. [Pathogenesis, symptoms, diagnostics and treatment of tuberculosis in HIV patients. Doct. Diss.]. St. Petersburg, 2012, 236 p.

11. Frolova O.P., Rakhmanova А.G., Priymak А.А. et al. The specific course of tuberculosis in HIV infected patients and measures aimed to prevent it. Journal Mikrobiologii, Epidemiologii i Immunobiologii, 1999, no. 1, pp. 67-69. (In Russ.)

12. Khaertynova I.M., Valiev R.Sh., Tsibulkin А.P. et al. Clinical and immunological specifics of HIV infection with concurrent tuberculosis. Probl. Tub., 2009, no. 6, pp. 41-46. (In Russ.)

13. Shakhgildyan V.I., Vasilieva T.E., Peregudova А.B. et al. Profiles, specific clinical course, diagnostics of opportunistic and concurrent diseases in HIV patients from an infectious diseases hospital in Moscow. Terapevt. Arkhiv, 2008, no. 11. (In Russ.)

14. Schelkanova А.I., Kravchenko А.V. Specifics of tuberculosis disease with HIV co-infection. Terapevt. Arkhiv, 2004, no. 4, pp. 20-24. (In Russ.)

15. Sharma S.K., Mohan A. Extrapulmonary tuberculosis. Indian J. Med. Res., 2004, vol. 120, pp. 316-353.

16. Yeh J.J., Chen S.C., Teng W.B. et al. Identifying the most infectious lesions in pulmonary tuberculosis by high-resolution multidetector computed tomography. Eur. Radiol., 2010, vol. 20, pp. 2135-2145.