Annals of Thoracic Medicine
ORIGINAL ARTICLE
Year
: 2007  |  Volume : 2  |  Issue : 2  |  Page : 58--60

Manifestation of tuberculosis in patients with human immunodeficiency virus: A large Indian study


S Rajasekaran, A Mahilmaran, S Annadurai, S Kumar, K Raja 
 Govt. Hospital of Thoracic Medicine, Tambaram Sanatorium, Chennai, India

Correspondence Address:
S Rajasekaran
Govt. Hospital of Thoracic Medicine, Tambaram Sanatorium, Chennai - 600 047
India

Abstract

Background: Government Hospital of Thoracic Medicine, Tambaram Sanatorium, Chennai, is the largest HIV-care center in South East Asia. As many as 29,300 HIV patients visited this center at least once in the year 2005 for care and support. Objectives: Clinical manifestations and the modes of presentation of tuberculosis were assessed among 12,750 adult and adolescent patients with human immunodeficiency virus (HIV) attending the hospital for the first time. Materials and Methods: Database of Hospital Information System, specially evolved for managing patients afflicted with tuberculosis and HIV, was utilized. The particulars confined to patients with tuberculosis and HIV co-infection who visited the hospital for the first time from January to December 2005 were considered for the analysis. Proportion test and Chi-square test with Yates correction were done. Results: As many as 12,750 adult and adolescent HIV-confirmed patients were screened for the possible presence of tuberculosis. Out of them, 4,383 (34.4%) patients had tuberculosis. Among them, 2,448 (55.9%) had pulmonary tuberculosis, and the remaining 1,935 (44.1%) had either disseminated or extra-pulmonary tuberculosis (P<0.001). Positive sputum-smear microscopy for acid fast bacilli was evident in 1,363 (31.1%) patients; however, it was significantly lower compared to positive smear rate of 44% in HIV patients (P< 0.001). Conclusion: Tuberculosis was found to be the predominant co-infection among the symptomatic patients infected with HIV attending the largest care center for the first time in India. Advanced tuberculosis, disseminated tuberculosis and sputum smear negative pulmonary tuberculosis were the presenting clinical manifestations in 44% of the patients, as they had moderate to advanced immunosuppression. Early detection of tuberculosis co-infection is absolutely necessary.



How to cite this article:
Rajasekaran S, Mahilmaran A, Annadurai S, Kumar S, Raja K. Manifestation of tuberculosis in patients with human immunodeficiency virus: A large Indian study.Ann Thorac Med 2007;2:58-60


How to cite this URL:
Rajasekaran S, Mahilmaran A, Annadurai S, Kumar S, Raja K. Manifestation of tuberculosis in patients with human immunodeficiency virus: A large Indian study. Ann Thorac Med [serial online] 2007 [cited 2020 Jul 14 ];2:58-60
Available from: http://www.thoracicmedicine.org/text.asp?2007/2/2/58/32231


Full Text

The human immunodeficiency virus (HIV) epidemic in India and other resource-limited countries is posing greater challenges to the containment of tuberculosis in HIV-afflicted individuals and collectively to the very control of tuberculosis. In the presence of infection with HIV, tuberculosis manifests in many ways; there may be primary tuberculosis, reactivated tuberculosis, or some patients may suffer from new TB infection (reinfection). [1] Studies conducted in rural [2] and urban [3],[4],[5],[6] India revealed a rising trend of HIV-TB co-infection. This is likely to have negative impact on the well-functioning TB-control program and the existing AIDS-control program. Clinical features of HIV-associated pulmonary tuberculosis in adults are frequently atypical, particularly in the late stage of HIV infection, with noncavitary disease, lower lobe infiltrates, hilar lymphadenopathy and pleural effusion. [7],[8] African countries affected by both TB and HIV are experiencing a disproportionate increase in smear-negative tuberculosis [9] and extra-pulmonary tuberculosis. [10] Diagnostic algorithms and treatment protocols must be developed for each country, taking into consideration various factors, including the commonly occurring opportunistic infections. This study provides an insight into the prevalence and clinical manifestations of HIV-TB co-infection among the patients attending for the first time the largest health care setting in India that provides care and support to such patients.

 Materials and Methods



Govt. Hospital of Thoracic Medicine, Tambaram Sanatorium, Chennai (GHTM, Tambaram), is the largest voluntary counseling and testing center in the country, providing HIV counseling and testing to more than 2,400 patients a month. All these patients are also screened for the possible coexistence of tuberculosis by performing sputum-smear microscopy for acid fast bacilli (AFB) and radiological investigations including chest radiography. Other specimens given by patients from extra-pulmonary sites are also subjected to smear microscopy.

Opportunistic infections were identified predominantly by laboratory investigations. Clinico-radiological methods and oxygen saturation were utilized in detecting pneumocystis carinii pneumonia. Computerized tomography and magnetic resonance imaging scans of brain helped in sorting out many central nervous system manifestations. Fine needle aspiration cytology and histopathological examination of the biopsied specimens were also resorted to wherever necessary.

Computerized database of Hospital Information System provides patient records and all the data analysis of various aspects of HIV-TB co-infection. This study is confined to the evaluation of manifestations of TB in adult and adolescent HIV patients who attended GHTM for the first time during 2005. Proportion test was done with the null hypothesis value of 50% to compare pulmonary vs. extra-pulmonary TB and the sex ratios. Chi-square test was done to compare the distribution among various age groups and smear-positive rates.

 Results



Twenty-nine thousand three hundred and eighty-six patients with HIV disease attended GHTM, Tambaram, at least once in 2005. As many as 13,348 patients visited the institution for the first time; out of them, 12,750 were aged 15 years and above, and they formed the study population for further analysis.

Among all the opportunistic infections that coexisted with 12,750 HIV patients, oral candidiasis (52%) and Pneumocystis carinii (jiroveci) pneumonia (42%) were found to be more frequent than tuberculosis (34%). Lower respiratory tract infection, including pneumonia, was found in 22% of the patients [Table 1].

Among 4,383 HIV-TB patients, 74.5% were males and the rest (25.5%) were females [Table 2] and the difference was statistically significant ( P P P P P [7],[8],[9],[10],[11],[12],[13],[14] as the hallmark of advanced HIV disease. This is the resultant of unrecognized [15] and demonstrable [16] Mycobacteremia in severely immunosuppressed patients.

Among all the HIV-TB patients, sputum smear positive detection rate was low (31% only). Advanced HIV disease is often associated with sputum smear negative pulmonary tubercuosis, [1],[7],[9] atypical radiographic pictures [17],[18],[19] and extra-pulmonary spread. Unrecognized tuberculosis in patients with HIV disease has far-reaching consequences, including delayed diagnosis, unacceptable therapeutic delay [20] and even rapid progression to 'untreatable TB.'

 Conclusion



Tuberculosis was found to be the predominant co-infection (34%) among the symptomatic HIV patients attending the largest HIV care center in India for the first time. Significantly, 44% patients were reporting with clinical manifestations of advanced tuberculosis, indicating the associated moderate to severe immunosuppression. Smear-negative pulmonary tuberculosis and extra-pulmonary tuberculosis are likely to pose diagnostic dilemma to clinicians used to treat tuberculosis in non-HIV patients. Early detection of varied forms of tuberculosis among HIV seropositives is absolutely necessary for instituting appropriate antituberculosis treatment well before the disease gets disseminated.

 Acknowledgment



The authors are grateful to all the clinicians, nurses and the entire laboratory staff of GHTM, Tambaram, for their valuable support. The assistance of Dr. L. Jeyaseelan, Professor and Head, Department of Biostatistics, Christian Medical College, Vellore, India, in providing statistical analysis is gratefully acknowledged. They are also thankful to Mr. Dhananjayan and the data entry team for providing and compiling the data of the patients.

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