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• W2010418311 abstract "In this issue of Chest, Flora et al (see page 1056) report 11 fatal cases of tuberculosis (TB) in HIV-infected persons. Although ten of these individuals sought medical attention 3-11 weeks before death, none was diagnosed correctly, and none received treatment for TB. Furthermore, the diagnostic evaluation was inadequate. None of these patients underwent tuberculin skin testing. Despite the presentation of 9 of 11 patients with pulmonary findings, sputum smears for acid-fast bacilli were performed in only three cases. This report leads to the disturbing conclusion that the significance of TB as a complication of HIV infection is not adequately appreciated. The Facts Tuberculosis should be considered prominently in the differential diagnosis when HIV-infected patients present with a consistent clinical syndrome for the following reasons: 1)TB is an early complication of HIV infection, occurring a mean 6-9 months before the diagnosis of an AIDS-defining condition in 50-67 percent of patients.1Sunderam G McDonald RJ Maniatis T Oleske J Kapila R Reichman LB Tuberculosis as a manifestation of the acquired immunodeficiency syndrome (AIDS).JAMA. 1986; 256: 362-366Crossref PubMed Scopus (333) Google Scholar, 2Louie E Rich LB Holzman RS Tuberculosis in non-Haitian patients with acquired immunodeficiency syndrome.Chest. 1990; 90: 542-545Crossref Scopus (86) Google Scholar, 3Handwerger S Mildvan D Senie R McKinley FW Tuberculosis and the Acquired Immunodeficiency Syndrome at a New York City Hospital: 1978-1985.Chest. 1987; 91: 176-180Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar, 4Chaisson RE Schecter GF Theuer CP Rutherford GW Echenberg DF Hopewell PC Tuberculosis in patients with the acquired immunodeficiency syndrome. Clinical features, response to therapy, and survival.Am Rev Respir Dis. 1987; 136: 570-574Crossref PubMed Scopus (392) Google Scholar, 5Reider HL Cauthen GM Bloch AB Cole CH Holtzman D Snider DE et al.Tuberculosis and acquired immunodeficiency syndrome-Florida.Arch Intern Med. 1989; 149: 1268-1273Crossref PubMed Google Scholar, 6Modilevsky T Sattler FR Barnes PF Mycobacterial disease in patients with human immunodeficiency virus infection.Arch Intern Med. 1989; 149: 2201-2205Crossref PubMed Scopus (159) Google Scholar Early treatment should have maximal impact on overall morbidity in this setting.2)TB, even in its disseminated form in HIV-infected patients, is relatively responsive to chemotherapy.2Louie E Rich LB Holzman RS Tuberculosis in non-Haitian patients with acquired immunodeficiency syndrome.Chest. 1990; 90: 542-545Crossref Scopus (86) Google Scholar, 4Chaisson RE Schecter GF Theuer CP Rutherford GW Echenberg DF Hopewell PC Tuberculosis in patients with the acquired immunodeficiency syndrome. Clinical features, response to therapy, and survival.Am Rev Respir Dis. 1987; 136: 570-574Crossref PubMed Scopus (392) Google Scholar, 7Pitchenik AE Burr J Suarez M Fertel D Gonzalez G Moas C Human T-cell lymphotrophic virus-III (HLTV-III) seropositivity and related disease among 71 consecutive patients in whom tuberculosis was diagnosed.Am Rev Respir Dis. 1987; 135: 875-879Crossref PubMed Scopus (130) Google Scholar3)HIV-infected patients with TB seem as infectious as their HIV-seronegative counterparts.7Pitchenik AE Burr J Suarez M Fertel D Gonzalez G Moas C Human T-cell lymphotrophic virus-III (HLTV-III) seropositivity and related disease among 71 consecutive patients in whom tuberculosis was diagnosed.Am Rev Respir Dis. 1987; 135: 875-879Crossref PubMed Scopus (130) Google Scholar Therefore, TB constitutes a hazard to household,7Pitchenik AE Burr J Suarez M Fertel D Gonzalez G Moas C Human T-cell lymphotrophic virus-III (HLTV-III) seropositivity and related disease among 71 consecutive patients in whom tuberculosis was diagnosed.Am Rev Respir Dis. 1987; 135: 875-879Crossref PubMed Scopus (130) Google Scholar hospital8Di Perri G, Danzi MC, de Checchi G, Pizzighella S, Solbiati M, Cruciani M, et al. Hospital infection. Lancet 1989; December 23/30, 1502-04Google Scholar or prison9Braun MM Truman BI Maguire B DiFerdinando Jr, G Wormser G Broaddus R et al.Increasing incidence of tuberculosis in a prison inmate population.JAMA. 1989; 261: 393-397Crossref PubMed Scopus (125) Google Scholar contacts, and specifically to health care workers.7Pitchenik AE Burr J Suarez M Fertel D Gonzalez G Moas C Human T-cell lymphotrophic virus-III (HLTV-III) seropositivity and related disease among 71 consecutive patients in whom tuberculosis was diagnosed.Am Rev Respir Dis. 1987; 135: 875-879Crossref PubMed Scopus (130) Google Scholar, 10Mycobacterium tuberculosis transmission in a health clinic-Florida, 1988.MMWR. 1989; 38: 256-264PubMed Google Scholar HIV-infected contacts are at particular risk; in one outbreak, 8 of 18 hospital contacts developed active TB.8Di Perri G, Danzi MC, de Checchi G, Pizzighella S, Solbiati M, Cruciani M, et al. Hospital infection. Lancet 1989; December 23/30, 1502-04Google Scholar4)Active TB is associated with immunosuppression and the activation of cells which harbor HIV;11Ellner JJ Immune dysregulation in tuberculosis.J Lab Clin Med. 1986; 108: 142-149PubMed Google Scholar, 12Ellner JJ Immunoregulatory function of mononuclear phagocytes in tuberculosis.in: Friedman H Bendinelli M Tuberculosis: Interactions with the immune system. Plenum Publishing, New York1988: 243-262Crossref Google Scholar these concomitants of TB may promote HIV activity and disease.11Ellner JJ Immune dysregulation in tuberculosis.J Lab Clin Med. 1986; 108: 142-149PubMed Google Scholar, 12Ellner JJ Immunoregulatory function of mononuclear phagocytes in tuberculosis.in: Friedman H Bendinelli M Tuberculosis: Interactions with the immune system. Plenum Publishing, New York1988: 243-262Crossref Google Scholar Any patient wth HIV infection could have TB. The risk varies with the a priori risk of tuberculosis infection, and, therefore, is highest in the foreignborn, intravenous drug abusers, blacks, and Hispanles.1Sunderam G McDonald RJ Maniatis T Oleske J Kapila R Reichman LB Tuberculosis as a manifestation of the acquired immunodeficiency syndrome (AIDS).JAMA. 1986; 256: 362-366Crossref PubMed Scopus (333) Google Scholar, 7Pitchenik AE Burr J Suarez M Fertel D Gonzalez G Moas C Human T-cell lymphotrophic virus-III (HLTV-III) seropositivity and related disease among 71 consecutive patients in whom tuberculosis was diagnosed.Am Rev Respir Dis. 1987; 135: 875-879Crossref PubMed Scopus (130) Google Scholar, 13Tuberculosis and acquired immunodeficiency syndrome-New York City.MMWR. 1987; 36: 785-795PubMed Google Scholar In geographic areas where HIV infection occurs predominantly in these groups, the frequency of TB in HIV-infected patients is high (8–21 percent) and may exceed that of M avium infection.1Sunderam G McDonald RJ Maniatis T Oleske J Kapila R Reichman LB Tuberculosis as a manifestation of the acquired immunodeficiency syndrome (AIDS).JAMA. 1986; 256: 362-366Crossref PubMed Scopus (333) Google Scholar, 5Reider HL Cauthen GM Bloch AB Cole CH Holtzman D Snider DE et al.Tuberculosis and acquired immunodeficiency syndrome-Florida.Arch Intern Med. 1989; 149: 1268-1273Crossref PubMed Google Scholar, 7Pitchenik AE Burr J Suarez M Fertel D Gonzalez G Moas C Human T-cell lymphotrophic virus-III (HLTV-III) seropositivity and related disease among 71 consecutive patients in whom tuberculosis was diagnosed.Am Rev Respir Dis. 1987; 135: 875-879Crossref PubMed Scopus (130) Google Scholar In areas such as San Francisco, where homosexual males constitute 98 percent of the HIV-infected population, 66 percent of HIV-TB cases were, however, in Americanborn whites, and 80 percent in homosexual males.4Chaisson RE Schecter GF Theuer CP Rutherford GW Echenberg DF Hopewell PC Tuberculosis in patients with the acquired immunodeficiency syndrome. Clinical features, response to therapy, and survival.Am Rev Respir Dis. 1987; 136: 570-574Crossref PubMed Scopus (392) Google Scholar Most TB in HIV infection involves the lungs, and atypical presentation is typical. Approximately 75 percent of patients will have pulmonary manifestations, one-third of them with concurrent extrapulmonary disease. The remaining 25 percent have extrapulmonary TB only,1Sunderam G McDonald RJ Maniatis T Oleske J Kapila R Reichman LB Tuberculosis as a manifestation of the acquired immunodeficiency syndrome (AIDS).JAMA. 1986; 256: 362-366Crossref PubMed Scopus (333) Google Scholar, 4Chaisson RE Schecter GF Theuer CP Rutherford GW Echenberg DF Hopewell PC Tuberculosis in patients with the acquired immunodeficiency syndrome. Clinical features, response to therapy, and survival.Am Rev Respir Dis. 1987; 136: 570-574Crossref PubMed Scopus (392) Google Scholar, 7Pitchenik AE Burr J Suarez M Fertel D Gonzalez G Moas C Human T-cell lymphotrophic virus-III (HLTV-III) seropositivity and related disease among 71 consecutive patients in whom tuberculosis was diagnosed.Am Rev Respir Dis. 1987; 135: 875-879Crossref PubMed Scopus (130) Google Scholar, 13Tuberculosis and acquired immunodeficiency syndrome-New York City.MMWR. 1987; 36: 785-795PubMed Google Scholar of which lymphatic disease is most common. Prospective studies clearly show that most TB in HIV-infected patients occurs in individuals previously tuberculin skin-test positive,16Selwyn PA Hartel D Lewis VA Schoenbaum EE Vermund SH Klein RS et al.A prospective study of the risk of tuberculosis among intravenous drug users with human immunodeficiency virus infection.N Engl J Med. 1989; 320: 545-550Crossref PubMed Scopus (1279) Google Scholar and therefore represents reactivation. The findings on chest x-ray examination are more typical of primary tuberculosis.1Sunderam G McDonald RJ Maniatis T Oleske J Kapila R Reichman LB Tuberculosis as a manifestation of the acquired immunodeficiency syndrome (AIDS).JAMA. 1986; 256: 362-366Crossref PubMed Scopus (333) Google Scholar, 4Chaisson RE Schecter GF Theuer CP Rutherford GW Echenberg DF Hopewell PC Tuberculosis in patients with the acquired immunodeficiency syndrome. Clinical features, response to therapy, and survival.Am Rev Respir Dis. 1987; 136: 570-574Crossref PubMed Scopus (392) Google Scholar, 6Modilevsky T Sattler FR Barnes PF Mycobacterial disease in patients with human immunodeficiency virus infection.Arch Intern Med. 1989; 149: 2201-2205Crossref PubMed Scopus (159) Google Scholar, 14Pitchenik AE Rubinson HA The radiographic appearance of tuberculosis in patients with the acquired immune deficiency syndrome (AIDS) and pre-AIDS.Am Rev Respir Dis. 1985; 131: 393-396PubMed Google Scholar Cavitary lung disease is present in only 0–18 percent of patients.1Sunderam G McDonald RJ Maniatis T Oleske J Kapila R Reichman LB Tuberculosis as a manifestation of the acquired immunodeficiency syndrome (AIDS).JAMA. 1986; 256: 362-366Crossref PubMed Scopus (333) Google Scholar, 2Louie E Rich LB Holzman RS Tuberculosis in non-Haitian patients with acquired immunodeficiency syndrome.Chest. 1990; 90: 542-545Crossref Scopus (86) Google Scholar, 6Modilevsky T Sattler FR Barnes PF Mycobacterial disease in patients with human immunodeficiency virus infection.Arch Intern Med. 1989; 149: 2201-2205Crossref PubMed Scopus (159) Google Scholar, 13Tuberculosis and acquired immunodeficiency syndrome-New York City.MMWR. 1987; 36: 785-795PubMed Google Scholar, 14Pitchenik AE Rubinson HA The radiographic appearance of tuberculosis in patients with the acquired immune deficiency syndrome (AIDS) and pre-AIDS.Am Rev Respir Dis. 1985; 131: 393-396PubMed Google Scholar, 15Fournier AM Dickinson GM Erdfrocht IR Cleary T Fischl MA Tuberculosis and nontuberculosis mycobacteriosis in patients with AIDS.Chest. 1988; 93: 772-775Crossref PubMed Scopus (41) Google Scholar Mid- and lower-lung infiltrates are present in 29 percent, hilar and/or mediastinal adenopathy in 20–59 percent, pleural effusions in 12–28 percent, apical infiltrates in 6–21 percent, a miliary pattern in 7–18 percent, and a normal chest x-ray picture with positive sputum cultures in 12 percent. The findings of intrathoracic adenopathy and pleural effusions are particularly useful in suggesting the diagnosis of TB, as they are not characteristics of Pneumocystis carinii pneumonia (PCP). On the other hand, PCP complicates as many as 25 percent of the cases of TB.15Fournier AM Dickinson GM Erdfrocht IR Cleary T Fischl MA Tuberculosis and nontuberculosis mycobacteriosis in patients with AIDS.Chest. 1988; 93: 772-775Crossref PubMed Scopus (41) Google Scholar Tuberculin skin testing is useful. In a prospective study, seven of eight cases of tuberculosis occurred in individuals previously shown to be tuberculin positive.16Selwyn PA Hartel D Lewis VA Schoenbaum EE Vermund SH Klein RS et al.A prospective study of the risk of tuberculosis among intravenous drug users with human immunodeficiency virus infection.N Engl J Med. 1989; 320: 545-550Crossref PubMed Scopus (1279) Google Scholar Anergy was present in only 27 percent of HIV-infected individuals, 47 percent of whom were entirely asymptomatic.16Selwyn PA Hartel D Lewis VA Schoenbaum EE Vermund SH Klein RS et al.A prospective study of the risk of tuberculosis among intravenous drug users with human immunodeficiency virus infection.N Engl J Med. 1989; 320: 545-550Crossref PubMed Scopus (1279) Google Scholar The risk of development of TB in a tuberculin-positive HIV-infected individual is approximately 7 percent per year. Overall, 39–56 percent of HIV-infected patients with active TB are tuberculin positive.3Handwerger S Mildvan D Senie R McKinley FW Tuberculosis and the Acquired Immunodeficiency Syndrome at a New York City Hospital: 1978-1985.Chest. 1987; 91: 176-180Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar, 5Reider HL Cauthen GM Bloch AB Cole CH Holtzman D Snider DE et al.Tuberculosis and acquired immunodeficiency syndrome-Florida.Arch Intern Med. 1989; 149: 1268-1273Crossref PubMed Google Scholar, 8Di Perri G, Danzi MC, de Checchi G, Pizzighella S, Solbiati M, Cruciani M, et al. Hospital infection. Lancet 1989; December 23/30, 1502-04Google Scholar Sixty-seven percent of patients developing TB before AIDS are tuberculin-positive, as contrasted with 33 percent if TB occurs concurrently with or after the diagnosis of AIDS.5Reider HL Cauthen GM Bloch AB Cole CH Holtzman D Snider DE et al.Tuberculosis and acquired immunodeficiency syndrome-Florida.Arch Intern Med. 1989; 149: 1268-1273Crossref PubMed Google Scholar The available data on skin testing are based on a cut-point of 10 mm; once the new criterion for a positive reaction in the setting of HIV infection of ≥5 mm17US Department of Health and Human Services, Public Health Service, Centers for Disease ControlTuberculosis and human immunodeficiency virus infection: Recommendations of the Advisory Committee for the Elimination of Tuberculosis (ACET).MMWR. 1989; 38 (243-50): 236-238PubMed Google Scholar is applied, the sensitivity of this test will increase accordingly. The yield of AFB smear (60–83 percent) and culture of the sputum in patients with pulmonary TB is excellent, and unaffected by the presence of HIV infection.5Reider HL Cauthen GM Bloch AB Cole CH Holtzman D Snider DE et al.Tuberculosis and acquired immunodeficiency syndrome-Florida.Arch Intern Med. 1989; 149: 1268-1273Crossref PubMed Google Scholar, 6Modilevsky T Sattler FR Barnes PF Mycobacterial disease in patients with human immunodeficiency virus infection.Arch Intern Med. 1989; 149: 2201-2205Crossref PubMed Scopus (159) Google Scholar, 7Pitchenik AE Burr J Suarez M Fertel D Gonzalez G Moas C Human T-cell lymphotrophic virus-III (HLTV-III) seropositivity and related disease among 71 consecutive patients in whom tuberculosis was diagnosed.Am Rev Respir Dis. 1987; 135: 875-879Crossref PubMed Scopus (130) Google Scholar The finding of AFB on sputum smear is more typical of TB than disseminated infection with M avium.6Modilevsky T Sattler FR Barnes PF Mycobacterial disease in patients with human immunodeficiency virus infection.Arch Intern Med. 1989; 149: 2201-2205Crossref PubMed Scopus (159) Google Scholar, 15Fournier AM Dickinson GM Erdfrocht IR Cleary T Fischl MA Tuberculosis and nontuberculosis mycobacteriosis in patients with AIDS.Chest. 1988; 93: 772-775Crossref PubMed Scopus (41) Google Scholar Bronchoalveolar lavage has a yield of positive AFB smears of approximately 50 percent.6Modilevsky T Sattler FR Barnes PF Mycobacterial disease in patients with human immunodeficiency virus infection.Arch Intern Med. 1989; 149: 2201-2205Crossref PubMed Scopus (159) Google Scholar Blood cultures also are positive in 42 percent of patients, and AFB smear and culture of the stool has a yield of 40–50 percent.6Modilevsky T Sattler FR Barnes PF Mycobacterial disease in patients with human immunodeficiency virus infection.Arch Intern Med. 1989; 149: 2201-2205Crossref PubMed Scopus (159) Google Scholar The Message Every HIV-infected individual should have tuberculin skin testing and receive preventive therapy with isoniazid if a positive reaction (≥5 mm of induration at 48 hours) is found. Routine skin testing should be performed in facilities serving individuals at high risk of HIV infection. Routine screening for HIV infection should be performed in individuals with extrapulmonary TB or 24–55 years of age with pulmonary TB, as well as others with TB at high risk for HIV infection. Every HIV-infected patient with pulmonary symptoms should have a tuberculin skin test (unless known to be tuberculin positive), sputum samples for AFB smear and culture, blood cultures for AFB, stool smear and culture for AFB, and, where appropriate, a bronchoalveolar lavage. If the chest roentgenogram is consistent with tuberculosis (apical infiltrate, cavitary lesion, hilar or mediastinal adenopathy, a miliary pattern, or pleural effusion) every attempt should be made to establish the diagnosis. Pending the outcome of the cultures, and in the absence of an alternative diagnosis adequate to explain the clinical findings, empirical antituberculosis therapy should be considered in this setting; it is mandatory if the patient is tuberculin positive or from a group at high risk of tuberculous infection. Ventilation must be adequate in areas used to administer inhalation therapy. Health care workers with frequent exposure to HIV-infected individual should have regular tuberculin skin testing. If these guidelines are followed, the impact of TB in HIV infection can be lessened. ACKNOWLEDGMENT: The helpful comments of Dr. Dixie E. Snider and Mr. Harry Stern, Centers for Disease Control, are appreciated." @default.
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• W2010418311 title "Tuberculosis in the Time of AIDS The Facts and the Message" @default.
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