ABSTRACT. Tuberculosis is said to be one of the commonest opportunistic infection in patients with HIV/. AIDS. A study was carried out to study the clinical, ...
ORIGINAL ARTICLE
Clinical Profile of Tuberculosis in Patients with HIV Infection/AIDS Praveen Kumar, Niraj Sharma, N.C. Sharma1 and Sudhakar Patnaik Rajan Babu T.B. Hospital and Infectious Diseases Hospital1, G.T.B. Nagar, Delhi
ABSTRACT Tuberculosis is said to be one of the commonest opportunistic infection in patients with HIV/ AIDS. A study was carried out to study the clinical, bacteriological and radiological features of HIV/TB patients. Over a period of two years, a total of 301 tuberculosis patients were suspected to have HIV/AIDS co-infection, and upon testing, 42 patients were found to be HIV seropositive. Most of the study patients were manual labourers followed by truck drivers. Sexual (heterosexual) route was found to be the major risk factor for HIV/AIDS. The most common symptom in these patients was cough and expectoration, followed by fever and weight loss. Acid-fast bacilli (AFB) smear positivity was found in 21.4% patients. On chest skiagram, infiltrative lesions were commonly seen in 61.9% patients. Extra-pulmonary tubercular manifestations were seen in 45.6% of HIV/TB cases. Key words : Human immunodeficiency virus; Acquired immunodeficiency syndrome; Tuberculosis.
[Indian J Chest Dis Allied Sci 2002; 44 : 159-163]
INTRODUCTION With the advent of HIV infection, tuberculosis has emerged as a major opportunistic infection, particularly in developing countries1. Due to the destructive effects of HIV on the immune system, particularly the cell mediated immunity, it not only favours the progression of tuberculosis infection, whether new or old, to clinically active tuberculosis but also worsens the severity of the disease and promotes its transmission2. In persons dually infected with HIV and tuberculosis, the lifetime risk of developing tuberculosis is 50-70% as compared to a 10% risk in HIV negative individuals3. Due to this relationship there has been a dramatic increase in the incidence of tuberculosis in countries with high prevalence
of HIV and tuberculosis4. In India, 56% of AIDS patients have been reported to be suffering from tuberculosis5. Thus, because of the very frequent association of tuberculosis and HIV, it has become necessary to look for tuberculosis in HIV infected individuals and vice-versa. The present study was carried out on hospitalized tuberculosis patients who were screened for HIV co-infection on the basis of the presence of one or more risk factors for HIV/AIDS.
MATERIAL AND METHODS The study was conducted on in-patients of R.B.T.B. Hospital during the period from July 1997 to June 2000. Based on a strong suspicion o f HIV/AIDS in fection , e.g . presence of
Correspondence : Dr Praveen Kumar, Senior Chest Physician, R.B.T.B. Hospital, Guru Teg Bahadur Nagar, Delhi-110 009; Tele.: 91-11-7213146.
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significant weight loss, prolonged fever, chronic diarrhea, oro-pharyngeal candidiasis, etc., along with history of known risk factors like promiscuous sexual behaviour, intravenous drug abuse or previous blood transfusion, 301 patients in this period were subjected to screening tests for anti-HIV antibodies (TRIDOT Kits, J. Mitra & Co., India), after pre-test counselling and informed consent. Confirmation of the positive screening results was obtained by Western blot from a reference laboratory (N.I.C.D., Delhi, using INNOLIA HIV-1/HIV-2, Antibody Innogenetics, Belgium). A detailed clinical history and complete general physical and systemic examination findings of HIV/TB patients were recorded. Besides routine blood examination, sputum was examined for acid-fast bacilli and pyogenic organisms. In cases of extra-pulmonary tuberculosis relevant samples were obtained for mycobacterial and histopathological examinations. For lymph node tuberculosis the diagnosis was based on FNAC/biopsy cytopathology and/or microbiological evidence of tuberculosis. Pleural effusion was diagnosed on biochemical, microbiological and cytological characteristics of aspirated fluid, and in cases of doubt, pleural biopsy was performed to confirm the diagnosis. Similarly in cases of meningitis, CSF analysis was done to prove the etiology and appropriate tests were carried out. In patients where no definite diagnosis could be established, signs of improvement after initiating anti-tuberculosis therapy were noted. For diagnosis of other opportunistic infections, other appropriate tests were carried out, wherever required. Important radiological features of these patients were also noted.
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seropositives most of the patients (29, 69%) belonged to the age group of 21-40 years, while one (2.4%) each was 61 years in age and nine (21.6%) fell in the 41-60 years agerange. In all, there were thirty-eight (90.5%) males and four (9.5%) females. Majority of patients (38.1%) were manual labourers while truck drivers and farmers accounted for 21.4% and 11.9%, respectively. Other occupations (19%) included rickshaw pullers, local bus conductors/drivers, safai karamcharies and vegetable vendors. All the four female patients (9.5%) were housewives. All the patients in the study group had a history of heterosexual contact, except one who was an intravenous drug user for the past four years. All the four females gave history of their partners being promiscuous in sexual activity.
RESULTS
Tuberculin anergy (< 5 mm induration to 1TU PPD) was observed in 36 (85.7%) patients. Rest six (14.3%) patients had positive tuberculin reactivity (>5 mm induration to 1TU PPD). Of these six patients, four (9.5%) patients had tuberculin positivity in the range of 5-9 mm, and one (2.4%) patient each had positivity in the range of 10-14 mm and 20-24 mm, respectively. Cough and expectoration were the most common symptoms observed in 97.6% patients, while 90.4% of the patients had a low-grade fever with night sweats, and anorexia with significant weight loss (>10% of the total body weight) was observed in 78.6% of the patients. Hemoptysis, diarrhea and peripheral lymphadenopathy were observed in 13 (31%), 17 (40.5%) and five (11.9%), respectively. Oral thrush was observed in 12 (28.6%) and skin rashes in one (2.4%) patient. Neurological symptoms (headache, altered sensorium, seizures, etc.) were reported by three (7.2%) patients.
The study involved a total of 301 tuberculosis patients with a strong suspicion of HIV/AIDS co-infection. Out of these, forty-two patients were found to be HIV seropositives (after confirmatory tests). All these 42 patients also fulfilled the surveillance case definition for HIV/ AIDS as given by WHO 3 . Out of these 42
Unilateral involvement of the lung on chest skiagram was observed in 35.7% and bilateral lesions in 38.1 per cent. Infiltrative lesions were found in 26 (61.9%) patients, with six (12.5%) having upper zone infiltrates and eight (19.2%) each having mid and lower zone involvement. Bilateral diffuse infiltrative lesions were seen in
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nine (21.7%), while caviation, miliary pattern and intra-thoracic lymphadenopathy were observed in seven (16.8%) patients each. Chest radiographs also revealed pleural effusion in three (7.3%) patients and bilateral hydropneumothorax in one (2.4%) patient. Direct smear examination for AFB in sputum specimens was positive in 21.4% patients, while the rest (78.6%) were smear negative. Six patients had pyogenic organisms isolated in their sputa. A total of 19 (45.6%) of the HIV-TB cases had extra-pulmonary tubercular lesions. Fifteen (35.6%) patients had extra-pulmonary lesions co-existent with pulmonary involvement. Out of the four patients without pulmonary evidence of tuberculosis, two (4.8%) had only intrathoracic lymphadenopathy and the remaining two had pleural effusion co-existent with cervical adenopathy. Peripheral lymphadenopathy was seen in five ( 11.9%) patients, intrathoracic in seven (16.8%) patients, and abdominal (peripancreatic and retro peritoneal) in one (2.4%) patient. Pleural involvement was seen in four (9.5%) patients with three having pleural effusion and one (2 .4%) having bilateral hydropneumothorax. A common associated infection seen was oral candidiasis that was observed in 12 (28.6%) patients. Bacterial pneumonias were found in six (14.4%) patients co-existent with pulmonary tuberculosis. DISCUSSION Human immunodeficiency virus (HIV) related immunosuppression among tuberculosis-infected individuals is the greatest single risk factor for developing tuberculosis6. Tuberculosis with HIV/AIDS co-infection often has an atypical presentation. Fortunately, tuberculosis in HIV/AIDS is curable as in immunocompetent hosts7. Most of our study group patients (76%) belonged to the age group of 20-39 years, while in the sexually active age and is also the most productive in one's life. Of all the detected
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patients 90.5% were males and the rest were females. The striking male predominance noted in the present study has also been reported by other workers in India8-13 and abroad6,14,15. The occupational profile of our patients revealed that a majority of them were labourers followed by truck drivers. All the four female patients were housewives with promiscuous male partners. Rajasekaran et al9 reported that majority of their patients were from the farming profession, while the transporters accounted for a smaller portion. Purohit et al 1 1 and Thanasekaran et al16 reported that majority of their patients were truckers. Mohanty et al13 reported 36.8% patients working as manual labourers while the majority 80% of the female seropositives were commercial sex workers. The percentage of the professions is thus seen to vary in different studies, largely due to the differences in the occupational patterns and the source from where the patients were selected. Sexual route (heterosexual) was found to be the major risk factor (97.6%) while only one patient was an intravenous drug abuser in our study. None of the patients contacted HIV infection through blood/blood product transfusion. Heterosexual promiscuity and casual sex was found to be a major risk factor in the studies by other Indian observers9,11,13,16-18 while Sunderam et al 1 4 observed that the majority of their cases were intravenous drug abusers (68.9%) and Chaisson et al19 showed that 80% of their subjects were homosexuals. The duration of illness in our patients ranged from one month to 2.5 years. The wider range can be attributed to the fact that most of our patients had received anti-tuberculosis treatment in the past and were either not cured or had defaulted treatment. Purohit et al 1 1 found that the duration of illness in their cases before seeking treatment was 1-9 months, while Arora et al17 showed that their patients had a short history of illness (< six months). Studies from North America suggest that tuberculosis was reported at a median interval of three months before AIDS was diagnosed19,20. Tuberculosis positivity (>5 mm) to ITU PPD was observed in 14.3% patients in our study.
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Other authors have reported a wide variation in tuberculin positivity12,13,16,19,21-23. Positive response to tuberculin is generally retained early in the course of HIV infection. The most common symptom was cough and expectoration in 41 (97.6%) patients, while fever was present in 38 (90.4%) and weight loss in 33 (78.6%) patients, One of our patients was diagnosed as a case of cryptococcal meningitis along with pulmonary tuberculosis. In the series reported by Purohit et al11 Mohanty et al13 and Gupta et al 1 1 fever was the most common complaint, while Thanasekaran et al 1 6 , Deivanayagam et al8 and Arora et al17 reported cough with expectoration in majority of their patients. The cumulative data published by NACO 24 in 5204 AIDS patients indicates that 89% patients had weight loss, 88% had fever, 86% had diarrhea and cough was seen only in 68 per cent. Sunderam et al14 and Chaisson and Slutkin 23 had also reported majority of their patients having fever, cough and weight loss. Nine (21.4%) of our patients had sputum smear for AFB positive as only a minority (16.8%) of our cases had cavitary lesions. Rajasekaran et al 9 and others 8,13,17 reported 15.33% patients as smear positive. It has been shown that sputum smear is often positive in the early stage of HIV infection3. The typical radiological features of postprimary tuberculosis, i.e. upper zone infiltrates and cavitary lesions were seen in 16.8% and 14 .5 % respectiv ely in o ur p atients, wh ile atypical features, such as lower zone infiltrates, intrathoracic lymphadenopathy, miliary and diffuse sh adows on ch est skiagrams were observed in 19.2%, 16.8%, 16.8% and 21.7% cases, respectively. Chest radiographs also revealed a pleural effusion in three (7.3%) patients and bilateral hydropneumothorax in one (2.4%) patient. In mild immunosuppression the appearance is often classical while in severe immunosuppression, atypical appearance has been observed2,8,9,11,13,18,24,27,29. Lesions reported by other authors include pulmonary infiltrates (7.056.3%), cavitation (25-53%), miliary shadows (6.3-16.7%) and diffuse (12.5-31.3%) lesions9,11,13,14,16-19,22. Intrathoracic lymphadeno-
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pathy was observed in 3.5-7.3%, while pleural involvement was seen in 7.0-25% of the cases. Extra-pulmonary tuberculosis is more common in HIV/TB patients, especially with advanced immunosuppression than in nonHIV/TB patients3. Extra-pulmonary tuberculosis was seen in 19 (45.6%) of our HIV/TB patients, of which 15 (35.6%) had simultaneous pulmonary disease. Lymphadenopathy was observed in 13 (30.9%) cases and pleural involvement in four (9.5%) of our patients. Other authors have also observed that lymphatic system is the most commonly involved, followed by pleural involvement in HIV/TB patients3,11,16-19,22,26. All the patients in our series were put on short course chemotherapy (SCC) with antituberculosis drugs as recommended by WHO3 . The dose and duration of the drugs prescribed were similar as that for non-HIV/TB patients, Case fatality is less in HIV/TB patients treated with SCC as compared to the conventional chemotherapy. The response to SCC as well as recurrence rates after completion of treatment is similar in HIV positive and HIV negative tuberculosis patients3 .
ACKNOWLEDGEMENT We are grateful to Dr U.K. Baweja, Consultant Microbiology, AIDS Division, National Institute of Communicable Disease, Delhi for her help in performing confirmatory tests (Western Blot) for HIV/AIDS at her laboratory.
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