Hiv tb case studies
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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

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HIV/TB – Case Studies

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Hiv tb case studies

HIV/TB – Case Studies

David Schlossberg, MD, FACP

Medical Director, TB Control Program

Philadelphia Department of Health


Hiv tb case studies

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

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

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

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


Hiv tb case studies

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

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

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

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.


Hiv tb case studies

www.milartgl.com/HTML/


Hiv tb case studies

Immune Reconstitution Syndrome

(Paradox, “HAART Attacks”)

HAART + anti-TB Rx: up to 35%

  • Lung infiltrate

  • Lymphadenitis

  • Intracranial tuberculoma

  • Subcutaneous abscess

  • Etc., etc., etc.


Hiv tb case studies

Vidal J, et. al. Rev. Inst. Med. Trop. S. Paulo vol.45 no.3 São Paulo May/June 2003


Hiv tb case studies

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

Management of IRIS

  • Rule out other causes

  • Continue ART and anti-TB Rx

  • Treat symptomatically

    • NSAIDS

    • Corticosteroids


Try to prevent iris

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

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


Hiv tb case studies

Thank You!


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