Download - HIV/aids and tuberculosis

Sonja HoogendoornEkwendeni Mission Hospital21-01-2016

HIV/aids and tuberculosis

HIV (human immunodeficiency virus)

HIV/AIDS Case presentation Tuberculosis HIV and TB Conclusion References

• RNA virus• Retrovirus• Host cell is CD4+ lymphocytes

The HIV life cycle

HIV/AIDS Vraagstelling Flowchart Artikel Conclusie Discussie ReferentiesHIV/AIDS Tuberculosis HIV and TB Conclusion ReferencesHIV/AIDS Case presentation Tuberculosis HIV and TB Conclusion References

3) Integration – enzyme integrase inserts viral DNA in DNA of host cells

1) 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

HIV/AIDS

• CD4+ lymphocytes destruction– CD4+ 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 daily– Natural immune responses against infected cells (CD8+ T-cells, antibodies, natural killer cells)

HIV/AIDS Tuberculosis HIV and TB Conclusion References

CD4+ count falls, viral load increases

Cellular immunodeficiency


HIV

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• Weakened immune system• High risk of opportunistic infections and malignancies

Acquired immunodeficiency syndrome (AIDS)

HIV/AIDS Tuberculosis HIV and TB Conclusion ReferencesHIV/AIDS Case presentation Tuberculosis HIV and TB Conclusion References

Case presentation• 41-year-old HIV-infected male, CD4

count unknown, not on ART, no co-trimoxazole prophylaxis

• Coughing since 5 weeks, antibiotics given without improvement

• T37.9, P111 bpm, RR 26, palpable enlarged (2 cm) cervical and axillary lymph nodes. Chest clear.

• Sputum smear negative twice

• Normal pneumonia• PCP• TB• ..

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Chest x-ray: infiltrate, large heart


WHO clinical stagingHIV/AIDS Vraagstelling Flowchart Artikel Conclusie Discussie ReferentiesHIV/AIDS Tuberculosis HIV and TB Conclusion ReferencesHIV/AIDS Case presentation Tuberculosis HIV and TB Conclusion References

Tuberculosis (TB)

HIV/AIDS Tuberculosis Flowchart Artikel Conclusie Discussie Referenties

• Mycobacterium tuberculosis– Transmission through air (cough, sneeze, talk, spit)

• Active vs latent (‘sleeping’) TB infection– 1/3 of the world population is infected with M. tuberculosis– Compromised 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 Tuberculosis HIV and TB Conclusion References

= HIV/aids


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)


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 symptoms– Absence of fever or cough does not rule out TB– The higher the CD4 count, the more typical the presentation


Sputum smear microscopy


• Smear-positive pulmonary TB– One bacilli (M. tuberculosis)

• Smear-negative pulmonary TB: most common form of TB in Malawi

– Inconclusive chest X-ray but a positive HIV test or clinical evidence of HIV and a clinical presentation compatible with TB

– Abnormalities 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


Chest X-ray


• Radiographic findings suggestive of TB:– Upper lobe infiltrates– Cavitary lesions– Hilar and/or paratracheal lymphadenopathy

• In HIV infection:– Lower lobe infiltrates (like bacterial pneumonia)– A miliary or ‘scattered seed’ like pattern– Lung cavities are rare

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

negative


Perihilar and paratracheal lymphadenopathy

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Miliary TB with typical ‘snowstorm’ appearance


Cavitary lesion



Extra-pulmonary TB•22% of all TB cases in Malawi are EPTB

– More in HIV+ patients

Presentation (apart from fever, weight loss and night sweats)

Pleural TB Chest 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 meningitis Headache, 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 TB Shortness of breath, oedema (swollen legs, abdomen), chest painLarge heart. Pericardial effusion or pericardial thickening on US

Lymphadenitis TB LN >2 cm in size, painless swelling, localized# Commonly affects posterior cervical and supraclavicular lymph nodes

Spinal TB/ osteoarticular TB

Back pain, leg weakness, urinary and bowel incontinence (compression of spinal cord). Slow onset of monoarthritis with low or little pain.


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 months• RH daily for 7 months


Treatment HIV


• All TB/HIV co-infected patients should be started on ART within the first 2 weeks of TB treatment, regardless of CD4 count• WHO stage 3 or 4

• All HIV-positive TB patients should be started on co-trimoxazole preventive therapy (CPT)


Prognosis


• TB is the most common cause of death among HIV-infected people worldwide• 1:4 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


Take home message

• TB often presents atypical in HIV-infected patients

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


Case presentation• 41-year-old HIV-infected male, CD4

count unknown, not on ART, no co-trimoxazole prophylaxis

• Coughing since 5 weeks, antibiotics given without improvement

• T37.9, P111 bpm, RR 26, palpable enlarged (2 cm) cervical and axillary lymph nodes. Chest clear.

• Sputum smear negative twice

• Normal pneumonia• PCP• TB• ..


Chest x-ray: infiltrate, large heart


Case presentation

• TB can cause all of the symptoms:• Chronic cough• Large lymph nodes• Large heart due to pericardial effusion

• PCP causes cough, but not large lymph nodes or large heart

• US: fluid around the heart


= smear-negative pulmonary and extrapulmonary TB involving the pericardium and lymph nodes


References1. Malawi National Tuberculosis Control Programme Manual. Ministry

of Health, Malawi, 2012.2. Malawi Guidelines for Clinical Management of HIV in Children and

Adults. Ministry of Health, Malawi, 2014.3. 2015-2020, National Strategic Plan for HIV and aids. National AIDS

commission Malawi, 2014. 4. Jon F. Fielder, MD. Tuberculosis in the era of HIV, a clinical manual

for care providers working in Africa and other resource-limited settings.

5. HIV Curriculum for the health professional. Baylor College of Medicine, 2010.

6. Oxford handbook of tropical medicine. Robert Davidson, Andrew Brent, Anna Seale. Oxford University Press, 2014.

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