HIV/aids and tuberculosis

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  • Sonja HoogendoornEkwendeni Mission Hospital21-01-2016HIV/aids and tuberculosis

  • HIV (human immunodeficiency virus)

    RNA virusRetrovirusHost cell is CD4+ lymphocytes

    HIV/AIDSCase presentationTuberculosisHIV and TBConclusionReferences

  • The HIV life cycle

    3) Integration enzyme integrase inserts viral DNA in DNA of host cells Binding and entry proteins recognize CD4+ cells and attack and invade them

    2) Reverse transcription enzyme reverse transcriptase enables the virus to transform RNA into DNA

    4) Replication HIV uses host DNA for synthesis of new HIV proteins

    HIV/AIDSVraagstellingFlowchartArtikelConclusieDiscussieReferenties

    HIV/AIDSTuberculosisHIV and TBConclusionReferences

    HIV/AIDSCase presentationTuberculosisHIV and TBConclusionReferences

  • HIV

    CD4+ lymphocytes destructionCD4+ cells have a shortened life span as a result of the viruses using them as factories to produce 10 million to 10 billion new viruses dailyNatural immune responses against infected cells (CD8+ T-cells, antibodies, natural killer cells)

    CD4+ count falls, viral load increases

    Cellular immunodeficiency

    HIV/AIDS

    HIV/AIDSTuberculosisHIV and TBConclusionReferences

    HIV/AIDSCase presentationTuberculosisHIV and TBConclusionReferences

  • HIV

    Weakened immune systemHigh risk of opportunistic infections and malignancies

    Acquired immunodeficiency syndrome (AIDS)

    HIV/AIDSVraagstellingFlowchartArtikelConclusieDiscussieReferenties

    HIV/AIDSTuberculosisHIV and TBConclusionReferences

    HIV/AIDSCase presentationTuberculosisHIV and TBConclusionReferences

  • Case presentation41-year-old HIV-infected male, CD4 count unknown, not on ART, no co-trimoxazole prophylaxis Coughing since 5 weeks, antibiotics given without improvementT37.9, P111 bpm, RR 26, palpable enlarged (2 cm) cervical and axillary lymph nodes. Chest clear. Sputum smear negative twice

    Normal pneumoniaPCPTB..

    Chest x-ray: infiltrate, large heart

    InleidingVraagstellingFlowchartArtikelConclusieDiscussieReferenties

    HIV/AIDSTuberculosisHIV and TBConclusionReferences

    HIV/AIDSCase presentationTuberculosisHIV and TBConclusionReferences

  • WHO clinical staging

    HIV/AIDSVraagstellingFlowchartArtikelConclusieDiscussieReferenties

    HIV/AIDSTuberculosisHIV and TBConclusionReferences

    HIV/AIDSCase presentationTuberculosisHIV and TBConclusionReferences

  • Tuberculosis (TB)

    Mycobacterium tuberculosisTransmission through air (cough, sneeze, talk, spit)

    Active vs latent (sleeping) TB infection1/3 of the world population is infected with M. tuberculosisCompromised immune system > reactivation (tuberculosis wakes up) > progression to active TB disease

    Pulmonary TB vs extra-pulmonary TB (EPTB)EPTB: pleura, lymph nodes, meninges, pericardium, etc. PTB: person infects on average 10-20 people

    = HIV/aids

    HIV/AIDSTuberculosisFlowchartArtikelConclusieDiscussieReferenties

    HIV/AIDSTuberculosisHIV and TBConclusionReferences

    HIV/AIDSCase presentationTuberculosisHIV and TBConclusionReferences

  • HIV and TB

    The risk of active TB in individuals with latent infection is increased 20-fold by HIV coinfection (WHO, 2009)Without ART, 30% of those with latent TB will develop active TB at some point during their lives (AIDS, 2001)It can occur in every range of CD4 counts

    About 56% of TB patients are HIV-positive (2013)

    HIV/AIDSTuberculosisFlowchartArtikelConclusieDiscussieReferenties

    HIV/AIDSTuberculosisHIV and TBConclusionReferences

    HIV/AIDSCase presentationTuberculosisHIV and TBConclusionReferences

  • Clinical TB suspect

    Any of the following current symptoms of any duration: cough, fever, weight loss, night sweats.Other symptoms:Respiratory symptoms (shortness of breath, chest pains, haemoptysis)Constitutional symptoms (loss of appetite)

    Most HIV patients with TB do not have typical TB symptomsAbsence of fever or cough does not rule out TBThe higher the CD4 count, the more typical the presentation

    HIV/AIDSTuberculosisFlowchartArtikelConclusieDiscussieReferenties

    HIV/AIDSTuberculosisHIV and TBConclusionReferences

    HIV/AIDSCase presentationTuberculosisHIV and TBConclusionReferences

    When the immune system is weak, there is not a big fight between TB and the body, resulting in a atypical presentation

  • Sputum smear microscopy

    Smear-positive pulmonary TBOne bacilli (M. tuberculosis)

    Smear-negative pulmonary TB: most common form of TB in MalawiInconclusive chest X-ray but a positive HIV test or clinical evidence of HIV and a clinical presentation compatible with TBAbnormalities on chest X-ray consistent with active pulmonary TB plus a positive HIV test OR no improvement with a course of broad-spectrum antibiotics

    HIV-infected patients with TB are less likely to have positive sputum smears than HIV-negative TB patients

    HIV/AIDSTuberculosisFlowchartArtikelConclusieDiscussieReferenties

    HIV/AIDSTuberculosisHIV and TBConclusionReferences

    HIV/AIDSCase presentationTuberculosisHIV and TBConclusionReferences

  • Chest X-ray

    Radiographic findings suggestive of TB:Upper lobe infiltratesCavitary lesionsHilar and/or paratracheal lymphadenopathy

    In HIV infection:Lower lobe infiltrates (like bacterial pneumonia)A miliary or scattered seed like patternLung cavities are rare

    A normal x-ray does not rule out TB in patients with compatible symptoms and clinical findingsIn 10-20% of HIV-positive patients with PTB, the chest X-ray is negative

    HIV/AIDSTuberculosisFlowchartArtikelConclusieDiscussieReferenties

    HIV/AIDSTuberculosisHIV and TBConclusionReferences

    HIV/AIDSCase presentationTuberculosisHIV and TBConclusionReferences

  • Perihilar and paratracheal lymphadenopathy

    InleidingVraagstellingFlowchartArtikelConclusieDiscussieReferenties

    HIV/AIDSTuberculosisHIV and TBConclusionReferences

    HIV/AIDSCase presentationTuberculosisHIV and TBConclusionReferences

  • Miliary TB with typical snowstorm appearance

    InleidingVraagstellingFlowchartArtikelConclusieDiscussieReferenties

    HIV/AIDSTuberculosisHIV and TBConclusionReferences

    HIV/AIDSCase presentationTuberculosisHIV and TBConclusionReferences

  • Cavitary lesion

    InleidingVraagstellingFlowchartArtikelConclusieDiscussieReferenties

    HIV/AIDSTuberculosisHIV and TBConclusionReferences

    HIV/AIDSCase presentationTuberculosisHIV and TBConclusionReferences

  • Extra-pulmonary TB

    22% of all TB cases in Malawi are EPTBMore in HIV+ patients

    HIV/AIDSTuberculosisFlowchartArtikelConclusieDiscussieReferenties

    Presentation (apart from fever, weight loss and night sweats)Pleural TBChest pain, shortness of breath. Absent breath sounds, dullness to percussion. One sided pleural effusion. # TB is one of the most common causes of a unilateral pleural effusion TB meningitisHeadache, confusion/coma, altered mental status, neck stiffnessCSF with between 100-500 cells/mm3 with lymphocyte predominance, high protein and low glucose# if HIV positive, cryptococcal meningitis is more likely Pericardial TBShortness of breath, oedema (swollen legs, abdomen), chest painLarge heart. Pericardial effusion or pericardial thickening on USLymphadenitis TBLN >2 cm in size, painless swelling, localized# Commonly affects posterior cervical and supraclavicular lymph nodesSpinal TB/ osteoarticular TBBack pain, leg weakness, urinary and bowel incontinence (compression of spinal cord). Slow onset of monoarthritis with low or little pain.

    HIV/AIDSTuberculosisHIV and TBConclusionReferences

    HIV/AIDSCase presentationTuberculosisHIV and TBConclusionReferences

  • Treatment TB

    Goal: cure patient, prevent death, reduce transmission

    Intensive phase: RHZE daily for 2 months (2-5 tablets)Rifampicin (R), Isoniazid (H), Pyrazinamide (Z), Ethambutol (E)Continuation phase: RH daily for 4 months (2-5 tablets)

    If retreatment or TB meningitis, add streptomycin:SRHZE daily for 2 monthsRH daily for 7 months

    HIV/AIDSTuberculosisFlowchartArtikelConclusieDiscussieReferenties

    HIV/AIDSTuberculosisHIV and TBConclusionReferences

    HIV/AIDSCase presentationTuberculosisHIV and TBConclusionReferences

  • Treatment HIV

    All TB/HIV co-infected patients should be started on ART within the first 2 weeks of TB treatment, regardless of CD4 countWHO stage 3 or 4All HIV-positive TB patients should be started on co-trimoxazole preventive therapy (CPT)

    HIV/AIDSTuberculosisFlowchartArtikelConclusieDiscussieReferenties

    HIV/AIDSTuberculosisHIV and TBConclusionReferences

    HIV/AIDSCase presentationTuberculosisHIV and TBConclusionReferences

  • Prognosis

    TB is the most common cause of death among HIV-infected people worldwide1:4 HIV-infected patients dies of TB (WHO, 2009)Kenya 1:2, Botswana 2:5, Ivory Coast 1:3, Congo 2:5

    The mortality is higher in smear-negative PTB cases than in smear-positive cases

    HIV/AIDSTuberculosisFlowchartArtikelConclusieDiscussieReferenties

    HIV/AIDSTuberculosisHIV and TBConclusionReferences

    HIV/AIDSCase presentationTuberculosisHIV and TBConclusionReferences

  • Take home messageTB often presents atypical in HIV-infected patients

    Ask for cough, fever, night sweats and weight loss to all HIV-infected persons at every clinic visitBUT, absence of typical symptoms does not rule out TBAND, a negative sputum smear does not rule out TBAND, a normal chest x-ray does not rule out TB

    InleidingVraagstellingFlowchartArtikelConclusieDiscussieReferenties

    HIV/AIDSTuberculosisHIV and TBConclusionReferences

    HIV/AIDSCase presentationT