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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 1  |  Issue : 3  |  Page : 154-163

Treatment outcome of newly detected pulmonary Tuberculosis in HIV-seropositive and HIV-seronegative patients


Department of Medicine, Krishna Institute of Medical Sciences, Satara, Maharashtra, India

Date of Web Publication17-Aug-2014

Correspondence Address:
Virendra C Patil
Department of Medicine, Krishna Institute of Medical Sciences University, Dhebewadi Road, Karad, Satara - 415 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-3334.138884

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  Abstract 

Background: HIV infection is the strongest of all known risk factors for the development of tuberculosis. Tuberculosis is the most common opportunistic infection and the number one cause of death in HIV/AIDS patients in developing countries. Materials and Methods: The aim of this study is to assess and compare the outcome of pulmonary tuberculosis in HIV-seropositive and HIV-seronegative patients. This was cross-sectional, observational and prospective study conducted at tertiary care center in western Maharashtra from May 2010 to April 2012. A total 50, HIV-seronegative patients and 50 HIV-seropositive patients of both genders, with pulmonary tuberculosis fulfilling inclusion criterion (age > 18 years, newly detected pulmonary tuberculosis) were included in present cross-sectional, observational, prospective and comparative study. Results: Of the total 50 HIV-seropositive patients, 36 (72%) males were newly detected pulmonary tuberculosis (PTB) with mean age of 40.61 ± 8.74 years and 14 (28%) were females with mean age 37.72 ± 9.54 years. Of total 50 patients amongst HIV seronegative-group patients with PTB, 29 (58%) were males with mean age of 42.44 ± 5.79 years and 21 (42%) were females with mean age of 38.9 ± 7.91 years. A total 10/50 (20%) patients in HIV-seropositive group and 3/50 (6%) HIV-seronegative group had evidence of jaundice. There was a statistical difference between development of jaundices in HIV and HIV-seronegative group ['P' = 0.037]. Total 9/36 (25%) male patients and 2/14 (14.28%) females patients died in HIV-seropositive group with no death recorded amongst in HIV-seronegative groups with high mortality in HIV-seropositive group ['P' < 0.0001]. Total 4 male and 4 female patients had inflammatory response syndrome (IRIS). Total 40/50 (80%) patients were sputum negative at the end of 6 th month (2 nd follow-up) among HIV-seropositive group. Total 49/50 (98%) become a sputum negative at the end of 2 nd follow-up, 6 month among HIV-seronegative group there was a statistically significant difference between two group ['P' = 0.021]. Total 10/50 (20%) and 1/50 (2%) patients were diagnosed with multidrug resistant tuberculosis (MDR-TB) among HIV-seropositive group and HIV-seronegative group, respectively ['P' = 0.002]. There was high prevalence of middle and lower lobe lesions and bilateral extensive pulmonary tuberculosis (BEPT) in patients with HIV-seropositive group patients and upper lobe, miliary shadow and cavitary lesions in HIV-seronegative group patients ['P' < 0.02]. The cavitary lesions were significantly low in HIV-seropositive group with low CD+4 counts. Duration of stay was significantly more in HIV-seropositive group compared with HIV seronegative- seropositive group ['P' < 0.01]. Conclusions: We found high prevalence of MDR-TB pulmonary tuberculosis in HIV-seropositive patients. Mortality was significantly high in HIV-seropositive patients than HIV-seronegative patients. Jaundice was more prevalent in HIV-seropositive patients than HIV-seronegative patients. There was high prevalence of middle and lower lobe lesions and BEPT in patients with HIV-seropositive group patients and upper lobe, miliary shadow and cavitary lesions in HIV-seronegative group patients. The cavitary lesions were significantly low in HIV-seropositive group with low CD+4 counts. Duration of stay was significantly more in HIV-seropositive group compared with HIV-seronegative group. Success rate of directly observed treatment short-course was less (80%) in HIV-seropositive group.

Keywords: HIV/AIDS, HIV/tuberculosis coinfected, Multidrug resistant tuberculosis, pulmonary tuberculosis


How to cite this article:
Patil VC, Agrawal V, Kulkarni S. Treatment outcome of newly detected pulmonary Tuberculosis in HIV-seropositive and HIV-seronegative patients. CHRISMED J Health Res 2014;1:154-63

How to cite this URL:
Patil VC, Agrawal V, Kulkarni S. Treatment outcome of newly detected pulmonary Tuberculosis in HIV-seropositive and HIV-seronegative patients. CHRISMED J Health Res [serial online] 2014 [cited 2020 Aug 8];1:154-63. Available from: http://www.cjhr.org/text.asp?2014/1/3/154/138884


  Introduction Top


Tuberculosis (TB) is one of the major public health problems globally. An estimated one-third of the world's population is infected with the Mycobacterium tuberculosis, and the disease kills nearly 1.7 million people each year (WHO, 2009). On the other hand, HIV is currently, the most important predisposing factor for developing TB in individuals coinfected with M. tuberculosis. Tuberculosis-HIV co-infection is increasing at an alarming rate. In 2006, there were 9.2 million incident tuberculosis cases in the world, and among these 0.7 million cases were HIV-positive. In 2007, there were at least 1.37 million cases of HIV-positive TB i.e. about 15% of the total incidence (WHO, 2009). [1] Tuberculosis is the most common opportunistic infection and the number one cause of death in HIV/AIDS patients in developing countries. Tuberculosis is a major public health problem in India, which accounts for one-fifth of the global TB incident cases. It is estimated that annually around 330,000 Indians die due to TB. [2] The HIV epidemic has led to large increases in the frequency of smear-negative pulmonary tuberculosis, which has poor treatment outcomes and excessive early mortality compared with smear-positive disease. The emergence of resistance to antituberculosis drugs, and particularly of multidrug-resistant TB (MDR-TB), has become a major public health problem in many countries and an obstacle to effective global TB control. There is high prevalence of MDRTB in HIV-seropositive patients with drug toxicities of multiple drugs including antiretroviral drugs treatment (ART) and anti tubercular drugs (AKT). [3],[4] So far, there are very few studies conducted in India. This prospective study was conducted to compare clinical profile and outcome of newly detected pulmonary tuberculosis in HIV-seropositive and HIV-seronegative patients. We conducted a cross-sectional study to address the comparison of pulmonary tuberculosis in HIV and HIV-seronegative patients at tertiary care center in western Maharashtra.


  Materials and Methods Top


A cross-sectional study was conducted at tertiary care center in western Maharashtra from May 2010 to April 2012. This was cross-sectional, observational and prospective study conducted at Krishna Institute of Medical Sciences, Karad. The hospital has facilities for tuberculosis and HIV/AIDS diagnosis, treatment and monitoring. The protocol was approved by the Medical Research ethical Committee of Krishna Institute of Medical Sciences University, Karad. Oral informed and written consent was obtained from the patients prior to enrollment.

Study subjects

A total 50 HIV-seronegative patients and 50 HIV-seropositive patients of both genders, with newly diagnosed pulmonary tuberculosis fulfilling inclusion criteria were included in present study. The sample size of 50 was chosen so that at least 50 evaluable subjects would be available in HIV-seropositive patients. The enrollment of HIV negative TB patients was made concurrently till the desired number of HIV-seropositive patients had been admitted.

Aims and objectives

To assess the outcome of pulmonary tuberculosis and to compare with HIV-seropositive and HIV-seronegative patients.

Inclusion criteria

Patients with age > 18 years of both gender, newly detected pulmonary tuberculosis and not previously received AKT were included in present study.

Exclusion criteria

Patients with severely illness, other factors of immunesuppression and those who are already on AKT or defaulter or with relapse were excluded. Major complications of HIV disease like encephalopathy, renal or hepatic disease, malignancy or any end-stage disease and did not have any medical condition that might interfere with the management of the pulmonary tuberculosis like diabetes, convulsions, serious cardiac or renal disease were excluded.

Diagnosis of active pulmonary tuberculosis

Individuals with a history of cough of 3 weeks duration or more and not responding to routine line of management for upper respiratory tract infection were advised to give three sputum samples (usually two spot and one early morning collection) for sputum smear examination for acid-fast bacilli (AFB) using the Ziehl-Neelsen method and the smears were graded as per the World Health Organization (WHO) standards. Smear positive pulmonary tuberculosis patients were diagnosed using the following criteria as per the Revised National Tuberculosis Control Program (RNTCP) guidelines. All patients received DOTS treatment under RNTCP and they were treated with an initial intensive phase lasting for 2 months followed by a continuation phase, which lasted for 4 months. In the intensive phase, three to four anti-TB drugs were administered thrice weekly depending on the category of treatment prescribed; all the thrice, weekly doses were given under direct observation. In the continuation phase, the number of anti-TB drugs administered was reduced to two and only the first dose of the week was given under direct supervision while the remaining two doses in the week were self-administered. All the drugs were administered thrice a week in the following doses (mg): Isoniazid (600), rifampicin (450, 600, if weight more than 60 kg), pyrazinamide (1500), ethambutol (1200).

Detection of HIV infection

The reactivity in the enzyme-linked immunosorbent assay (ELISA) was confirmed by a rapid test (HIVTRI-DOT, Biotech Inc., India). HIV infection was diagnosed using three antigenically different rapid kits as per the national HIV testing policy.

Definition of cases

1. Newly detected pulmonary TB: The diagnosis of tuberculosis was made by a physician, based on presence of symptoms and signs compatible with TB and/or radiological evidence of active TB; demonstration of AFB from a clinical specimen (sputum). Suggestive clinical profile and empirical response to antitubercular therapy (ATT)

2. MDR-TB is defined as resistance to the two most effective first-line TB drugs: Rifampicin and isoniazid. [5] MDR-TB was diagnosed according to the report available from outside

3. Those cases, who had treatment failure were subjected to sputum culture and drug susceptibility tests. (By using the BACTEC MGIT960 instrument optimized for rapid detection of mycobacteria from the sputum. In cases of positive cultures, susceptibility testing for the isolates was done by 5649-AFB susceptibility: SIREP panel by Radiometry)

4. Immune reconstitution syndrome (IRS) was defined as paradoxical clinical deterioration temporally associated with start of antiretroviral therapy, TB-IRIS immune reconstitution inflammatory syndrome (IRIS) was defined as transient worsening or appearance of new symptoms, signs or radiographic manifestations after initiation of highly active antiretroviral therapy (HAART). Tuberculosis is the most frequent pathogen associated with IRIS, of which, lymph node enlargement is the most common manifestation. [6]

Laboratory procedure for tuberculosis diagnosis and Hematology

Sputum was collected in a plastic leak-proof container and examined for AFB under microscopy using Ziehl-Neelsen (Z.N.) method. The culture and drug susceptibility testing were done for MDR-TB. The blood sample was used for hemoglobin measurement (Hb), erythrocyte sedimentation rate (ESR), creatinine, liver function tests and for CD4+T cells count for HIV-seropositive patients. Chest radiogram was done for all patients with newly detected pulmonary tuberculosis in the present study. Tuberculosis and HIV/AIDS diagnosis, treatment and monitoring were done at Krishna Institute of Medical Sciences Karad according to the national policy for tuberculosis and HIV/AIDS management. Blood tests and chest radiogram were repeated at 2 months and at the end of treatment. CD4 cell counts were determined by flow-cytometry technique using Facs Count machine with Facscount™ reagents (Becton Dickinson, USA). CD4+T cell counts were done on all patients initially and at the end of treatment. [6]

Statistical analysis

Completed questionnaires were coded by numbers and double entered in a computer software SSPE-12 trial version. Categorical data were analyzed by Chi-square test. The level of significance was set at P ≤ 0.05, and 95% confidence interval was used throughout. [7]


  Results Top


A total 50 HIV patients and 50 HIV-seronegative patients where included in this prospective observational cross-sectional study. Of 50 HIV-seropositive patient newly detected pulmonary tuberculosis (PTB) 36 (72%) were males with mean age of 40.61 ± 8.74 years and 14 (28%) were females with mean age 37.72 ± 9.54 years. Of total 50 patients amongst HIV-seronegative group patients with newly PTB, 29 (58%) were males with mean age of 42.44 ± 5.79 years and 21 (42%) females with mean age of 38.9 ± 7.91 years. There was no statistical difference between HIV-seropositive patient and HIV-seronegative group patients [Chi-square: 2.1538,
P = 0.142]. The mean age in study population was 40.39 (±18) years. The mean for CD4 was (cells per microliter) count was 128.44 (±36).

Of total 50 newly detected PTB with HIV-seropositive patient 30/36 (83.33%) male patients had chest radiogram abnormalities suggestive of PTB and 9/14 (64.28%) female patients had chest radiogram abnormality suggestive of PTB. A total 6/36 (16.66%) males and females 5/14 (35.71%) had normal chest radiogram. Amongst HIV-seronegative group 23/29 (79.3%) males patients and 7/21 (33.3%) females patients had abnormal chest radiogram suggestive of PTB. Total 6/29 (20.68%) male and 14/21 (66.66%) female patients had normal chest radiogram. There was statistically significant difference between HIV and HIV-seronegative groups patients with abnormal chest radiogram [Chi- square: 3.56, P = 0.059] [Table 1] [Figure 1] and [Figure 2].
Figure 1: Chest radiogram in HIV-seropositive patients

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Figure 2: Chest radiogram in HIV-seronegative patients

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Table 1: Comparison of radiographic fi ndings in HIV-seropositive and HIV-seronegative patients

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A total 23/36 (63.88%) and males 10/14 (71.42%) females patients were on ART [chi-sq: 0.25535; prob.=0.613 [statistically insignificant]. A total 33/36 (91.66%) males patients and 12/14 (85.71%) females had CD4 count less than 200 per cubic mm. A total 3/36 (8.33%) males patients and 2/14 (14.28%) females patients had CD4 count more than 200 micml/lt. Means CD4 count was 128.44 ± 36 [chi-sq: 0.39683; prob. = 0.529 [statistically insignificant].

A total 10/50 (20%) patients in HIV-seropositive group and 3/50 (6%) HIV-seronegative group had clinical/biochemical evidence of jaundice. There was a statistically difference between development of jaundice in HIV and HIV-seronegative group [Chi-square: 4.33, P = 0.037]. The jaundice was developed after starting AKT and were on ART simultaneously and favoring drug induced [AKT and or ART].

Total 9/36 (25%) male patients and 2/14 (14.28%) females patients died in HIV-seropositive group with no death amongst the HIV-seronegative groups. There was statistically significant difference for mortality with high mortality in HIV-seropositive group compared with HIV-seronegative group [Chi-square: 12.35, 'P < 0.0001]. Terminal event in HIV-seropositive group was ARDS with respiratory failure. Two patients had developed chronic cor pulmonale in HIV-seropositive group patients with bilateral extensive pulmonary tuberculosis (BEPT) [Table 2].
Table 2: Mortality in patients with pulmonary TB in HIV seropositive and negative status

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A total 21/36 (58.33%) males patients and 9/14 (64.28%) females patients were improved at the end of third month on follow up. In HIV-seropositive group on DOTS. Total 28/29 (96.55%) male patients and 21/21 (100%) females patients improved at the end of third month (1 st follow up) on DOTS in HIV-seronegative group. There was a statistically significant difference between two groups for improvement at the end of third month [Chi-square: 9.4697, 'P = 0.002] in HIV-seropositive group. Total 4 male and 4 female patients had IRIS who were on ART and developed new pulmonary infiltrates and findings suggestive of active pulmonary tuberculosis [Table 3].
Table 3: Outcome of patients with pulmonary TB in HIV
seropositive and negative statuses


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Total 26/36 (72.22%) males and 8/14 (57.14%) females had smear positive sputum for AFB in HIV group. Total 16/29 (55.17%) males and 14/21 (66.66%) females patients positive for sputum for AFB among HIV-seronegative group. There was no statistical difference between two group for sputum positivity [Chi-square: 0.69, P = 0.405] [Table 4]. Total 18/50 (36%) patients had a sputum negative at the end of third month and 32/50 (64%) were having sputum positivity or persistent x-ray finding and or clinical deteoriation in HIV-seropositive group. Total 47/50 (94%) were sputum negative at the end of third month and 3 were having either a sputum positivity or persistent x-ray finding or clinical detoriation in non-HIV group. There was significant difference between two groups for sputum positivity [Chi-square: 36.96, P < 0.0001]. Total 40/50 (80%) patients were sputum negative at the end of 6 th month (2 nd follow-up) among HIV-seropositive group. Total 49/50 (98%) become a sputum negative at the end of 2 nd follow-up, 6 month among HIV-seronegative group there was a statistically significant difference between two group [Chi-square: 5.322, P = 0.021] [Table 5].
Table 4: Sputum for AFB in HIV and HIV-seronegative patients

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Table 5: Sputum status after 6 months of AKT on 2nd follow-up

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Total 10/50 (20%) and 1/50 (2%) patients were diagnosed with MDR-TB among HIV-seropositive group and HIV-seronegative group, respectively. There was statistical significant difference between two groups with high incidence of MDR-TB among HIV-seropositive group [Chi-square: 9.4697, P = 0.002] [Table 6].
Table 6: Comparison of MDR-TB in HIV seropositive group and HIV-seronegative and seropositive patients

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Total 39 patients had abnormal chest radiogram suggestive of active pulmonary tuberculosis in HIV-seropositive group. Total 13 (33.33%) patients had upper lobe involvement in the form of infiltrates, pleural thickening and fibrosis. Total 11 (28.20%) patients had middle and lower lobe involvement in the form of infiltrates and patchy consolidation. Total 3 (7.69%) patients had miliary shadows in both lung fields. Total 5 (12.82%) patients had cavitary lesions in right lung fields. Total 7 (17.94%) patients had bilateral extensive pulmonary tuberculosis (BEPT). Total 22 patients had abnormal chest radiogram suggestive of active pulmonary tuberculosis in HIV-seronegative group. Total 15 (48.38%) patients had upper lobe involvement in the form of infiltrates, pleural thickening and fibrosis. Total 3 (9.67%) patients had middle and lower lobe involvement in the form of infiltrates and patchy consolidation. Total 5 (16.12%) patients had miliary shadows in both lung fields. Total 7 (22.58%) patients had cavitory lesions in right lung fields. Total 1 (3.22%) patients had bilateral extensive pulmonary tuberculosis (BEPT). There was high prevalence of middle and lower lobe lesions and BEPT in patients with HIV-seropositive group patients and upper lobe, miliary shadow and cavitory lesions in HIV-seronegative group patients ['P' <0.02]. The cavitory lesions were significantly low in HIV-seropositive group with low CD+4 counts [Table 7].
Table 7: Radiological fi ndings in chest radiogram in study population

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Total 25 patients were had hospital stay of <7 days and 25 had >7 days amongst HIV-seropositive group. Total 36 patients were had hospital stay of <7 days and 14 had >7 days amongst HIV-seronegative seropositive group. Duration of stay was significantly more in HIV-seropositive group compared with HIV seronegative-seropositive groups ['P' <0.01].

In multivariate analysis, after controlling age and gender, mortality rate, MDR-TB, duration of hospital stay, middle and lower lobe chest radiographic findings, jaundice and sputum for AFB positivity at the end of three months was significantly higher in HIV-seropositive patients with newly diagnosed pulmonary tuberculosis ('P' < 0.01).


  Discussion Top


The global impact of the converging dual epidemics of tuberculosis (TB) and human immunodeficiency virus (HIV) is one of the major public health challenges. Further, there has been an increase in rates of drug resistant tuberculosis, including multi-drug (MDRTB) and extensively drug resistant TB (XDRTB), which are difficult to treat and contribute to increased mortality. Treatment of HIV-TB co-infection is complex and associated with high pill burden, overlapping drug toxicities, risk of IRIS and challenges related to adherence. In present study, we compared the outcome of pulmonary TB in HIV-seropositive and HIV-seronegative patients. Our results were compared with various Indian and overseas studies. Solomon S et al., reported that 22 (91.67%) of a total of 24 HIV-seropositive pulmonary tuberculosis patients had pulmonary cavities and 21 patients (87.5%) had bacteriological confirmation of tuberculosis. [8] Similarly in the present study there was high prevalence of middle and lower lobe lesions and BEPT in patients with HIV-seropositive group patients and upper lobe, miliary shadow and cavitary lesions in HIV-seronegative group patients ['P' < 0.02]. The cavitory lesions were significantly low in HIV-seropositive group with low CD+4 counts. Patel AK et al., in their study of 50 patients, 40% had only pulmonary TB (PTB) and 25.58% was positive for AFB smear. Sputum smear AFB positivity is low in TB patients having HIV. [9] In contrast, in our study total 26/36 (72.22%) males and 8/14 (57.14%) females had smear positive sputum for AFB in HIV group. Total 16/29 (55.17%) males and 14/21 (66.66%) females patients were positive for sputum for AFB among the HIV-seronegative group, with high prevalence of sputum positivity for AFB. Purohit S D et al. quoted high mortality in HIV/TB infected group (66.6%). [10] Similarly, total 25% male patients and 14.28% females patients died in HIV-seropositive group with relatively low mortality. Mohammad Tahir et al. reported 27% sputum positive for AFB in their study with overall treatment success achieved in 86%. [11] Similarly, 72.22% males and 57.14% females had smear positive sputum for AFB in HIV group. Total 55.17% males and 66.66% female patients were positive for sputum for AFB among HIV-seronegative group with high prevalence of sputum positivity for AFB. Jaryal A et al., in their study of 87 HIV-infected patients with associated tuberculosis stated that early diagnosis of tuberculosis and prompt institution of antitubercular treatment (ATT) reduces mortality and morbidity significantly. [12] These findings are comparable with our study in which there was statistically significant difference with high mortality in HIV-seropositive group compare with HIV-seronegative group [Chi-square: 12.35, P < 0.0001]. Terminal event in HIV-seropositive group was ARDS with respiratory failure. Two patients had developed chronic corpulmonale in HIV-seropositive group patients with BEPT. Perriλns JH et al., concluded that, the efficacy of a short-course regimen of chemotherapy for pulmonary tuberculosis in HIV-seropositive and HIV-seronegative outpatients with their rates of treatment failure were similar. [13] In contrast in present study a total 40 (80%) patients were sputum negative at the end of six month (2 nd follow up) among HIV-seropositive group. Total 49/50 (98%) become a sputum negative at the end of 2 nd follow up 6 month among HIV-seronegative group ['P' = 0.021]. In present study the there was high mortality in HIV-seropositive group compare to HIV-seronegative group ['P' < 0.0001]. Chaisson RE et al. stated that, DOTS is highly efficacious in both HIV-seropositive and seronegative patients. [14] Similarly in present study with success rate of 98% in HIV-seropositive group and 80% in HIV-seronegative seronegative group with total 9/36 (25%) male patients and 2/14 (14.28%) females patients died in HIV-seropositive group with no death amongst in seronegative groups. El-Sadr WM et al., in their study found that, among HIV-infected patients cure and success rate was less and relapse rate was more. [15] Similarly in present study a total 40/50 (80%) patients were sputum negative at the end of six month (2 nd follow up) among HIV-seropositive group. Total 49/50 (98%) become a sputum negative at the end of 2 nd follow up 6 month among seronegative group there was a statistically significant difference between two group ['P' = 0.021] these findings are comparable with our study. Khan FA et al., they stated that, there was trends toward higher relapse rates if rifamycins were used for only 6 months, compared with > or = 8 months, or if antiretroviral therapy was not used. [16] This review raises serious concerns regarding current recommendations for treatment of HIV-tuberculosis coinfection. In present study a total 40/50 (80%) patients were sputum negative at the end of six month (2 nd follow up) among HIV-seropositive group. Total 49/50 (98%) become a sputum negative at the end of 2 nd follow up 6 month among HIV-seronegative group. Timothy R et al., found that, antiretroviral therapy has a profound effect on lowering the risk of TB in HIV-infected persons, but it can also be associated with immune reconstitution inflammatory disease and unmasking of previously subclinical disease. [17] These findings are comparable with present study, where total 10/50 (20%) patients in HIV-seropositive group and 3/50 (6%) HIV-seronegative group had clinical/Biochemical evidence of jaundices. There was a statistically difference between development of jaundices in HIV and HIV-seronegative group. In present study total 4 male and 4 female patients had IRIS (inflammatory response syndrome) who were on ART and developed new pulmonary infiltrates and findings suggestive of active pulmonary tuberculosis. S. Tripathy et al., in their study found that, at the end of the 6 th month of anti-TB treatment, 62% of the HIV-seropositive and 92% of the HIV negative smear negative patients completed treatment and were asymptomatic. [18] In present study, a total 18/50 (36%) patients had a sputum negative at the end of third month and 32/50 (64%) were having sputum positivity in HIV-seropositive group. Total 47/50 (94%) were sputum negative at the end of third month and 3 were having a sputum positivity in non-HIV group. There was significant difference between two groups for sputum positivity [Chi-square: 36.96, 'P'<0.0001]. Total 9/36 (25%) male patients and 2/14 (14.28%) females patients died in HIV-seropositive group with no death amongst HIV-seronegative groups. There was statistical significant difference for mortality with high mortality in HIV-seropositive group compared with HIV-seronegative group [Chi-square: 12.35, 'P' < 0.0001]. These findings are comparable with our results. Swaminathan S et al. reported that, tuberculosis has a varied clinical presentation in patients with HIV infection as per subjective immunological status. [19] These findings are comparable with our study in which, A total of 33/36 (91.66%) males patients and 12/14 (85.71%) females had CD4 count less than 200 per cubic mm. A total 3/36 (8.33%) males patients and 2/14 (14.28%) females patients had CD4 count more than 200 micml/lt. Mean CD4 count was 128.44 ± 36. Total 39 patients had abnormal chest radiogram suggestive of active pulmonary tuberculosis in HIV-seropositive group. Total of 13 (33.33%) patients had upper lobe involvement in the form of infiltrates, pleural thickening and fibrosis. Total of 11 (28.20%) patients had middle and lower lobe involvement in the form of infiltrates and patchy consolidation. Total of 3 (7.69%) patients had miliary shadows in both lung fields. Total of 5 (12.82%) patients had cavitary lesions in right lung fields. Total of 7 (17.94) patients had BEPT. There was high prevalence of middle- and lower-lobe lesions and BEPT in patients with HIV-seropositive group patients and upper lobe, miliary shadow and cavitary lesions in HIV-seronegative group patients ['P' < 0.02]. The cavitary lesions were significantly low in HIV-seropositive group with low CD+4 counts. Kassim S et al., stated that the HIV-positive patients had lower rates of completion of therapy (65-73%) than seronegative patients (79%), mainly because of increased mortality. [20] Rifampicin-containing short-course chemotherapy for pulmonary tuberculosis is associated with similar cure and recurrence rates in HIV-positive and HIV-negative persons completing 6 months of therapy. However, mortality is significantly increased in all seropositive groups compared with HIV-negative tuberculosis patients. Similarly, in present study a total of 80% patients was sputum negative at the end of 6 th month (2 nd follow up) among HIV-seropositive group and 98% among HIV-seronegative group. Similar to the present study, Bwire R et al., reported that HIV-seropositive status is not a principal factor in delaying sputum conversion among patients receiving intensive phase tuberculosis treatment. [21] Daniel OJ et al., in their study to compare the treatment outcome of TB/HIV-seropositive and TB/HIV-negative patients, Nigeria found that, 58 (16.4%) were HIV seropositive. [22] The cure rate was 76.8% patients. The cure rate was significantly lower in HIV infected compared with HIV seronegative infected TB patients (60.3% vs 80.0%; P = 0.0001). Overall mortality was 5.1%, which was significantly higher in HIV seropositive compared with HIV negative TB patients (15.5% v 3.1%; P = 0.00007). Mortality rate in TB/HIV-seropositive patients was higher than in HIV-negative patients. These findings are similar to our study where cure rate was less in seropositive group with high mortality. Swaminathan S et al., in their study found that at the end of two months of treatment, 91% of seropositive patients had sputum cultures negative for M. tuberculosis. [23] Similarly, in our study, success rate was 80% at the end of the 6 th month. Pili Kamenju et al., in their study of TB-HIV co-infection among of 387 TB patients found that there was significantly higher proportion of deaths among HIV-infected TB patients (29.1% versus 15.2%) than in the HIV-uninfected TB patients (P = 0.005). [24] These findings are comparable with present study. Nagai H et al., reported that, the incidence of HIV seropositivity was 3.2% in all TB patients, 28.6% in miliary TB patients, and 1.0% in typical TB patients. [25] Similarly in present study, a total of 3 (7.69%) patients had miliary shadows in both lung fields in HIV-seropositive group and (16.12%) in HIV-seronegative group. Hsieh SM et al. reported that, a primary tuberculosis pattern (hilar adenopathy, pleural effusion, middle or lower lobe infiltrates) in the chest radiographs was the most common radiological finding (36.4%) in patients with pulmonary TB. [26] The reactivation pattern (predominant upper-lobe infiltrates with or without cavitation) could only be found in cases of pulmonary TB without extrapulmonary involvement, these findings are comparable with our study. Punnotok J et al., stated that TB were more likely to have strains that are resistant to isoniazid (10.9% vs 3.5%; P < 0.001), rifampicin (9.4% vs 2.9%; P < 0.001), and at least isoniazid and rifampicin (multidrug-resistant TB [MDR-TB]; 5.2% vs 0.4%; P < 0.001). [27] Similarly in our study total 20% and 2% patients were diagnosed to MDR-TB among HIV-seropositive group and HIV-seronegative group, respectively. El-Sony AI et al., reported that the smear-positive cases showed a cure rate of 77.2% and a failure rate of 1%. [28] Cure rates for the smear-positive cases were 68.3% for HIV-positive and 77.6% for HIV-negative patients (P = 0.164). Case fatality was significantly higher among HIV-positive (12%) than among HIV-negative cases (1.8%) (OR 7.7, 95% CI 3.51-16.8). Similarly success rate of DOTS was 80% in HIV-seropositive patients in present study. Abouya L et al., stated that among HIV-infected patients with CD4 + counts of > or = 400/mm 3 , 200-399/mm 3 , and <200/mm 3 , respectively, the proportions with non-cavitary infiltrates and hilar adenopathy increased significantly, while the proportion with cavitary lesions decreased significantly. [29] Similarly, in present study there was high prevalence of middle- and lower-lobe lesions and BEPT in patients with HIV-seropositive group patients and upper lobe, miliary shadow and cavitory lesions in HIV-seronegative group patients ['P' < 0.02]. The cavitory lesions were significantly low in HIV-seropositive group with low CD+4 counts. Ahmadi F et al., reported that, atypical radiological features are explained by immunoradiological correlation, where the miliary disease, pleural effusion and lympahdenopathy occurs mostly in patients with CD4 lymphocyte level below 200/mm≥, while the cavitations occur more frequently with CD4 lymphocyte level above 200/mm≥. [30] Rajasekaran S et al., reported that, prevalence of HIV coinfection with MDR-TB was found to be high among chronic TB patients. [31] In present study we have total 20% patients, who were diagnosed with MDR-TB among HIV-seropositive group. Similarly, Deivanayagam CN., et al. reported 33.9% MDR-TB patients. [32] EU Nwonwu et al., reported, most common radiological features was cavitary lesions (64.1%), patchy opacities (44.4%), and hilar opacities (38.5%) with PTB/HIV co-infection. [33] Similarly in our study total of 7 (17.94) patients had BEPT in PTB/HIV co-infection. R Prasad et al., in their study observed that 90.1% patients remained asymptomatic, 7.2% patients had relapsed and 2.6% patients died during follow-up, and these findings are comparable with our results. [34] Datta BS et al., reported 52 (5.7%) cases of MDR-TB, among which eight (15.3%) were diagnosed as XDR-TB on the basis of drug susceptibility testing. [35] In present study, we have a total of 20% and 2% patients diagnosed to MDR-TB among HIV-seropositive group and HIV-seronegative group, respectively.

To improve the performance and impact of TB-control program, in the face of HIV co-infection and other constraints on DOTS, the World Health Organization has launched the revised 'Stop TB Strategy'. The new strategy, to be implemented via the Global Plan to Stop TB (2006-2015), includes intensified TB-case finding, treatment of latent TB infection with isoniazid, prevention of HIV infection, cotrimoxazole preventive therapy and ART.


  Conclusions Top


HIV infection is the strongest of all known risk factors for the development of tuberculosis. We found high prevalence of MDR pulmonary tuberculosis in HIV-seropositive patients in this setting. Atypical chest radiograph suggestive of tuberculosis was common findings in HIV/tuberculosis co-infected patients. Mortality was significantly high in HIV-seropositive patients than HIV-seronegative patients. Jaundice was more prevalent in HIV-seropositive patients than HIV-seronegative patients with newly detected pulmonary TB on anti-tubercular treatment, which was contributed by ART in HIV-seropositive group. There was high prevalence of middle- and lower-lobe lesions and BEPT in patients with HIV-seropositive group patients and upper lobe, miliary shadow and cavitory lesions in HIV-seronegative group patients. Tubercular co-infection is common in HIV infected and more so with falling CD4 cell level. The cavitory lesions were significantly low in HIV-seropositive group with low CD+4 counts. Duration of stay was significantly more in HIV-seropositive group compared with HIV-seronegative and seropositive groups. Success rate of DOTS was less in HIV-seropositive group at the end of the 6 th month. All patients seeking HIV care merit meticulous screening for tuberculosis and timely institution of appropriate treatment regimens for the dual diseases. We strongly support for strengthening of linkages between the RNTCP and National AIDS Control Program that would contribute towards early case detection and early treatment of the two diseases, thereby significantly reducing the morbidity and mortality associated with HIV/tuberculosis co-infected. The adequate knowledge of the manifestations of tuberculosis in HIV-infected patients is necessary for optimal management and to reduce mortality and morbidity.

 
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