Transcript Slide 1

HIV/TB – Case Studies
David Schlossberg, MD, FACP
Medical Director, TB Control Program
Philadelphia Department of Health
Case # 1
A 23 year-old African-American
man presents with a 3-week
history of fever, cough and
15 pound weight loss. He
admits to IVDA. Physical exam
is unremarkable except for
fever. Routine cultures are
negative, but AFB smear of
sputum is positive. HIV serology
is positive, with CD4 = 120.
TB in AIDS – Be suspicious!
• Often initial manifestation of AIDS
• ANY respiratory symptoms
– Suspect even with clear CXR
• Subclinical: NO resp symptoms and clear CXR
– Ten Tanzanian patients (2%) with CD4 >200
• Cultures positive in 10/10
• Smears negative in 7/10
Mtei et al, Clin Infect Dis 2005;40:1500-7
TB in Advanced AIDS
• Frequently atypical:
– CXR: clear, mid and lower lung zones,
effusion, adenopathy
– Extrapulmonary involvement common – up to
70%: lymphadenopathic, meningeal, hepatic,
renal, pleural, cutaneous, spinal, miliary
– PPD negative > 60%
– Exogenous reinfection possible
• May > reactivation in some sub-groups
Anti-TB Rx in HIV
• Same as in HIV- negative patients, except:
– Avoid once-weekly continuation phase
– Avoid twice-weekly Rx if CD4 <100
– Nine months if culture positive after 2 mos
– Six-month minimum, even for culture-negative
• Good response to therapy; early mortality
may be high, but relapse rate < 5%
• Drug interactions (rifamycins)
(www.cdc.gov/nchstp/tb/pubs/mmwrhtml/maj_guide.htm
Case # 2
A 29 year-old Hispanic woman with AIDS is
on HAART. Her viral load is undetectable,
and her CD4 count is 550. She was recently
exposed to a cousin with TB, and her PPD
is 17x20mm. She is asymptomatic, and her
CXR is normal. She just found out she is
pregnant.
LTBI in HIV
• HIV and TB feed on each other
– Immunosuppression is a risk for progression to TB
– MTB induces replication of HIV
• Progression of LTBI to TB disease:
– Nosocomial outbreak: 35% within 60 days
– 10% per year (vs. 10% lifetime risk if HIV-negative)
Therefore, treat LTBI aggressively
–
–
–
–
Pregnancy - any stage
Even with history of prior treatment
Even for contacts with negative PPD
9 months preferable to 6 months
Case # 3
A nineteen-year-old white male IVDA presented
with cavitary pulmonary TB and was found to be
HIV-positive (CD4 = 275). Both HAART and
anti-TB Rx were initiated, with good clinical
response. However, after 3 weeks, he developed
fever, new pulmonary infiltrates and intrathoracic
lymphadenopathy.
www.milartgl.com/HTML/
Immune Reconstitution Syndrome
(Paradox, “HAART Attacks”)
HAART + anti-TB Rx: up to 35%
• Lung infiltrate
• Lymphadenitis
• Intracranial tuberculoma
• Subcutaneous abscess
• Etc., etc., etc.
Vidal J, et. al. Rev. Inst. Med. Trop. S. Paulo vol.45 no.3 São Paulo May/June 2003
Subcutaneous abscess –
Immune Reconstitution
in patient with AIDS
And Miliary TB, on
HAART
http://www.itg.be/itg/DistanceLearning/LectureNotesVandenEndenE/imagehtml/ppages/CD_1082_013c.htm
Management of IRIS
• Rule out other causes
• Continue ART and anti-TB Rx
• Treat symptomatically
– NSAIDS
– Corticosteroids
Try to Prevent IRIS:
• Already on ART – just add anti-TB Rx
• Simultaneous Dx of HIV plus TB:
– CD4 > 350 - Start Anti-TB Rx + ART
– CD4 < 350 - Rx TB; Delay ART 4-8 weeks
• CD4 < 50 - some would start both ART + Anti-TB Rx
Take-Home Points: HIV + TB
•
•
•
•
•
TB is common
Immunosuppression causes unusual presentations
LTBI progression to TB is significant risk
Drug interactions are frequent
IRIS may mimic treatment failure or new infection
Thank You!