This material from the British organization NAM offers brief information on the diagnosis and treatment of tuberculosis in HIV-positive people.

Tuberculosis is a serious disease, usually affecting the lungs, which can be life-threatening if timely and appropriate treatment is not started. Tuberculosis is one of the most common infectious diseases in the world. Every year, 2 billion people in the world are diagnosed with tuberculosis, and every year, 3 million people die from tuberculosis. Tuberculosis became rare in industrialized countries many years ago, but its prevalence is still high in certain groups of the population - especially prisoners and social groups living in poor conditions. People with HIV, especially those with a weakened immune status, are most susceptible to tuberculosis. In the world, tuberculosis is the most dangerous opportunistic infection in the AIDS stage.

Tuberculosis in HIV-positive people

The onset of the AIDS epidemic is associated with an increase in tuberculosis cases in the world, since HIV and tuberculosis actively interact with each other. Both infections affect the immune system, changing the development of the other disease. As a result, HIV affects the symptoms and development of tuberculosis and in people with HIV, especially with an immune status below 200 cells/ml, tuberculosis often becomes extrapulmonary, that is, it does not affect the lungs, as in most cases, but other body systems, e.g. lymph nodes and spine, which is especially dangerous. The simultaneous presence of these infections can complicate the treatment of each of them.

Because HIV affects the immune system, weakening it, people with HIV are seven times more likely to get the tuberculosis pathogen. Also, in people with HIV who have latent TB, it is much more likely to become active. On average, for HIV-positive people with latent tuberculosis, the risk of developing active disease is 8-10% per year. For HIV-negative people with latent TB, the lifetime risk is only 5%. The lower the immune status of a person with HIV, the higher the risk of developing extrapulmonary tuberculosis.

Active tuberculosis also leads to an increase in HIV viral load, which can lead to decreased immune status and disease progression. Even after successful treatment for tuberculosis, the viral load may remain elevated.

Although antiretroviral therapy against HIV is the mainstay of preventing tuberculosis among people with HIV, even when HIV treatment is available, the risk of developing tuberculosis remains higher. However, antiretroviral therapy helps the immune system recover and prevents tuberculosis in most cases.

How is tuberculosis transmitted?

Tuberculosis is caused by a bacterium, Mycobacterium tuberculosis, which is transmitted from person to person through airborne transmission. The bacterium is found in droplets of lung fluid exhaled by a person with active pulmonary tuberculosis, which can be inhaled by someone nearby. TB is transmitted exclusively from people with active pulmonary TB, usually when that person sneezes, coughs, or talks. If a person has latent tuberculosis or an extrapulmonary form of tuberculosis, the bacterium cannot be transmitted from him to another person.

Once in the lungs, the bacteria begins to multiply. However, in most people (90-95%) the immune system is quite healthy and tuberclesis remains latent, that is, the disease does not develop. In people with HIV, the immune system may lose control of the bacterium, causing the bacterium to spread throughout the body and develop active tuberculosis. The disease can become active after several months or many years. In other words, Mycobacterium tuberculosis can reside in the human body for many years, but it becomes active and causes tuberculosis only when the immune system is weakened.

Symptoms of tuberculosis

The main symptom of the pulmonary form of active tuberculosis is a chronic cough. Symptoms of tuberculosis also include:

• Labored breathing.
• Sudden weight loss.
• Fever and fever.
• Increased night sweats.
• Severe chronic fatigue.
• Enlarged lymph nodes.

All of these symptoms are “classic” symptoms of pulmonary tuberculosis. However, in people with HIV they can have a variety of causes unrelated to tuberculosis. However, if these symptoms appear, you must consult a doctor to rule out tuberculosis.

People with very low immune status may suffer from "atypical" or "extrapulmonary" tuberculosis, which occurs when the bacteria spreads from the lungs to other organs. Tuberculosis can affect the lymph nodes; bone tissue, including the spine; tissues surrounding the heart (pericardium); membranes surrounding the lungs; organs of the digestive system; kidneys and urethra. Sometimes tuberculosis causes inflammation of the brain or spinal cord - meningitis. Symptoms of meningitis include irritability, insomnia, severe or worsening headaches, confusion, loss of consciousness and seizures.

With atypical tuberculosis, the symptoms depend on which organs or tissues the bacterium affects, but symptoms such as fever, severe chronic fatigue and sudden weight loss are “universal” for all forms of tuberculosis.

Diagnosis of tuberculosis

To diagnose latent tuberculosis, that is, to determine the presence of Mycobacterium tuberculosis, a tuberculin test (usually the Mantoux test) is most often used. During this test, TB protein is injected under the skin. After three days, redness should appear on the skin as a reaction of the immune system to the protein. The immune response to the test indicates the presence of past or current infection or vaccination. A large skin reaction most likely indicates infection with a bacterium. Unfortunately, the absence of a reaction does not prove the absence of a pathogen. With HIV, the immune system may be suppressed and a skin test may be negative even if the bacteria is present in the body. Also, vaccination against tuberculosis makes diagnosis by skin test difficult.

Recently, more accurate tests for active or latent infection have been developed - ELISPOT, which detects lymphocytes that react to fragments of two unique proteins of the bacterium. This test is more reliable and allows you to get results the next day. There are also other methods for determining the activity of the bacterium.

The gold standard for diagnosing active tuberculosis is the ability to grow a culture of the bacterium M. Tuberculosis in a patient's sputum sample. However, this process can take weeks or even months. Treatment of active tuberculosis cannot be delayed for such a period. Diagnosis and treatment are usually made by a combination of various factors, including symptoms, X-ray findings of the lungs, and microscopic examination of sputum.

It should be taken into account that in people with HIV, an X-ray for tuberculosis may look normal or similar to an X-ray for other lung diseases. In classic pulmonary tuberculosis, the sputum often contains bacteria, which can be visible under a microscope. The diagnosis of pulmonary tuberculosis can be made with a repeated positive sputum test result. However, this method is not as reliable for people with HIV.

Another problem is that sputum samples are more difficult to obtain in people with HIV, since they may not have a chronic cough with sputum. Sometimes this requires taking a sample of tissue from the lungs or lymph nodes for testing. Sometimes, if diagnosis is difficult, the doctor will prescribe antibiotics against tuberculosis to see if they will make the symptoms go away.

Extrapulmonary tuberculosis is the most difficult to diagnose. This often requires complex procedures to obtain tissue samples from the organ suspected of being affected by TB.

Treatment of latent tuberculosis

Often, in the absence of active tuberculosis, doctors recommend anti-tuberculosis drugs to get rid of latent infection. Sometimes people with HIV who have had a risk of transmitting M. tuberculosis in the workplace or home are also recommended preventative treatment. Indications for preventive treatment may include prisoners, miners, health care workers, and people who lived with people with active tuberculosis.

Different treatment regimens can reduce the risk of developing active tuberculosis in people with HIV. These include:

• A six-month course of isoniazid, 5 mg/kg every day or 14 mg/kg twice a week. Vitamin B6 is often prescribed along with isoniazid to prevent side effects and peripheral neuropathy. Some experts recommend a nine-month rather than a six-month course of treatment.
• A course of taking the drug rifampicin for three or four months with or without isoniazid.
• A two-month course of pyrazinamide and rifampicin. However, this course is risky in terms of toxic effects on the liver. However, there is evidence that this risk is small for HIV-positive patients.

Treatment with isoniazid is most common, especially for patients taking antiretroviral therapy, since rifampicin interacts with some drugs. However, rifampicin is a more effective drug against tuberculosis and is often reserved for the treatment of active tuberculosis to prevent the bacteria from developing resistance to the drug. Although a preventive course can rid the body of a latent infection, it cannot protect against new infections.

Taking drugs against tuberculosis also requires very precise adherence to the drug regimen, otherwise the pathogen may become resistant to treatment. Therefore, preventive treatment is recommended only for patients who can be relied upon to adhere to their medication regimen.

Treatment of active tuberculosis

Typically, first-line treatment for TB is the same for HIV-positive and HIV-negative people. However, there are differences specific to people with HIV.

There are two phases of treatment for tuberculosis. The intensive first phase should rid the body of the infection, then a long second phase begins, which should ensure the disappearance of the infection. For people who have not previously been treated for tuberculosis, a two-month course of isoniazid 4-6 mg/kg per day, rifampicin 8-12 mg/kg per day, pyrazinamide 20-30 mg/kg per day and ethambutol 15-20 is usually recommended. mg/kg per day.

To ensure that all of these medications are taken correctly, they are often taken under the supervision of a healthcare professional. This is called directly observed therapy. This is especially important as people begin to feel better and their TB symptoms disappear and may become less attentive to treatment. It is vitally important to complete the full course of treatment correctly to avoid relapse and drug resistance.

After two months, if sputum tests show nothing and the patient can no longer transmit the infection to others, a less intensive second phase of treatment begins. The second phase of treatment may vary in duration. There are two main approaches to maintenance treatment for tuberculosis:

• A four-month course of isoniazid and rifampicin. This regimen is preferred, but should only be prescribed if adherence to treatment is guaranteed, for example under direct observation.
• A six-month course of isoniazid and ethambutol, which can be prescribed to the patient during examinations once a month.

People with tuberculosis are often prescribed pyridoxine (vitamin B6) to take daily to reduce the side effects of isoniazid. In case of coinfection with HIV, it is also possible to simultaneously prescribe cotrimoxazole (Bactrim, Biseptol), which reduces morbidity and mortality in this group of patients.

Treatment of extrapulmonary tuberculosis

Many experts now agree that virtually all forms of extrapulmonary tuberculosis can be treated with regimens used for pulmonary tuberculosis, although in some cases treatment must be longer.

Some patients with extrapulmonary tuberculosis benefit from corticosteroid therapy, particularly those with pericarditis and meningitis. They are also effective for weight loss syndrome associated with tuberculosis.

Treatment of tuberculosis, contraception and pregnancy

For pregnant women, having HIV and tuberculosis increases the risk of transmitting both infections to the child. Treatment of latent and active tuberculosis is especially important for the health of both the mother and the unborn child.

Rifampin interacts with hormonal contraceptives and reduces their effectiveness. WHO recommends that women taking hormonal contraception increase their dosage when treating tuberculosis or switch to a different method of contraception.

Pregnant women with active tuberculosis should take isoniazid and rifampicin, which are safe for use during pregnancy. Pyrazinamide can also be prescribed, but its effect on pregnancy has been poorly studied. Ethambutol is not recommended during pregnancy. Streptomycin is dangerous for the fetus as it can cause hearing impairment.

Treatment of tuberculosis and antiretroviral therapy

One of the main dilemmas in treating tuberculosis in people with HIV is whether to treat tuberculosis first and then prescribe antiretroviral therapy; or simultaneous treatment of both infections should be started. Treatment of HIV and tuberculosis at the same time is possible, but it is associated with an increased risk of side effects, and some drugs are incompatible with each other.

Rifampicin interacts with protease inhibitors and non-nucleoside reverse transcriptase inhibitors, so it was previously recommended to delay the initiation of antiretroviral therapy, as well as interrupt it in the first stage of treatment for tuberculosis. However, the latest CDC guidelines recommend using the drug rifabutin instead of rifampicin, as well as changing the dosage of the drugs. However, rifabutin is not always available and is not commonly used in the UK because it has not been sufficiently tested in HIV-positive people.

If, according to clinical indications, it is impossible to delay the start of antiretroviral therapy, then the regimen can be selected in such a way as to be combined with rifampicin, usually by changing the recommended dosage of antiretroviral drugs.

Also, the combination of antiretroviral drugs and anti-tuberculosis antibiotics may be associated with the risk of additional side effects. For example, hepatitis can be a side effect of nevirapine, as well as anti-tuberculosis drugs: isoniazid, rifampicin and pyrazinamide.

Multidrug-resistant tuberculosis

Some strains of tuberculosis have become resistant to standard drugs - multidrug-resistant. Multidrug-resistant tuberculosis is the most dangerous in terms of high mortality, especially for HIV-positive people, if treatment is not started as early as possible and with carefully selected therapy.

Multidrug-resistant tuberculosis is much more easily transmitted, and in patients with such an infection it is more difficult to determine whether the risk of transmitting the bacterium to another person has disappeared or not. Therefore, multidrug-resistant tuberculosis usually requires hospitalization and isolation for several months.

It is much more difficult to treat multidrug-resistant tuberculosis and usually treatment requires additional drugs: streptomycin, kanamycin, clarithromycin, amikacin, kareomycin and other antibiotics. Typically, the treatment regimen consists of four drugs, plus two additional drugs that are expected to work against the strain of bacteria. Once the bacteria in the sputum has disappeared, people with multidrug-resistant tuberculosis undergo a course of at least three drugs over twelve months, with some experts recommend extending treatment to 18 or 24 months.

Immune inflammatory syndrome

Some people develop immune inflammatory syndrome while taking antiretroviral therapy. This means that while the immune system is restored, the symptoms of tuberculosis paradoxically worsen. This syndrome occurs in people with treated or active but asymptomatic tuberculosis, in whom antiretroviral therapy leads to a very rapid decrease in viral load and an increase in immune status. As the immune system is restored, immune cells begin to attack the areas where the bacteria are hiding.

Symptoms of this include fever, cough, difficulty breathing, swollen lymph nodes, or worsening signs of tuberculosis on X-ray. The syndrome is more common in people who start therapy with a very low immune status, below 50 cells/ml. Symptoms may begin within the first two months of taking antiretroviral therapy.

Most doctors believe that if this symptom is present, antiretroviral therapy should be continued unless the symptoms are life-threatening. Patients should also take anti-TB drugs even if cultures are negative for TB. There is some evidence that treatment with corticosteroids can reduce the manifestations of the syndrome.

Tell your friends:

Tuberculosis in HIV-infected people develops quite difficult. From the moment of diagnosis and detection of tuberculosis infection, the patient needs an early examination to detect HIV infection. And in the case of AIDS, it is necessary to consider patients as those who are most likely to be infected with tuberculosis. Therefore, let's look at the features of the course of tuberculosis with HIV, why this tandem is formed, and what is the life expectancy of a person with these ailments.

Two diseases can form a tandem in the following situations:

• primary development of tuberculosis in a patient with HIV;
• the occurrence of pathologies at the same time;
• formation of the disease based on immunodeficiency in AIDS.

Co-infection with AIDS increases the chances of developing tuberculosis. According to statistics, the probability of developing two pathologies (in a year) is 10%; for others, the risk is reduced to 5% over the entire life cycle. The occurrence of AIDS and tuberculosis together is possible when the immune system is severely weakened.

Among all patients with AIDS, about 40% have a positive response to HIV infection.

The patient has severe immunodeficiency, so it is not difficult for Koch’s bacillus to penetrate the body. A single contact with a patient with tuberculosis can lead to infection.

The source of this infection is a person who has such a pathology. In most cases, it is transmitted from patients with the disease in the final stage, but there is also a possibility for those who have shown the first signs. The most active spreaders are considered to be patients with a late stage of the disease.

All human fluids (blood, urine, saliva, semen, etc.) contain viral components to one degree or another. But the greatest danger comes from blood and seminal fluid.

The main reasons for the combination of the two described pathologies lie in the peculiarities of the mechanisms of formation of tuberculosis during HIV infection. It should be taken into account that the latter has an effect on immunoreactivity in tuberculosis. The interaction in cellular persistence begins to change, with macrophage differentiation collapsing.

Main signs of the disease

According to studies, the clinical picture of the course of the dual disease is not very different from the signs of pathology in patients who do not have immunodeficiency. In this case, the symptoms completely depend on the extent to which the disease has developed and what is the period of infection.

With pulmonary TB along with HIV infection, the symptoms completely depend on the order of infection. The malignant form of TB is observed with significant immunodeficiency; signs depend on the stability of cellular immunity.

Manifestation of the disease:

• feverish state, hyperhidrosis at night;
• lethargy, poor performance;
• cough that does not go away for three weeks;
• poor functioning of the stomach and intestines;
• sudden weight loss (about 10% of body weight);
• coughing up blood;
• discomfort in the chest area.

In addition to the blow to the lungs, damage to the lymph nodes is observed in HIV-infected people.

They have a dense structure, do not move when palpated and cause pain. They have a rather lumpy texture and are significantly increased in size.

Options for identifying a set of pathologies

Experts are of the same opinion: having identified a positive response to an HIV test, it is necessary to immediately identify the risk group susceptible to the formation of tuberculosis. The examination is carried out to further monitor the dynamics of the development of the disease. A phthisiatrician, based on the tests obtained, will be able to prescribe the correct course of therapy, which can improve the patient’s condition, even at the very later stages.

The main activities carried out upon receipt of positive HIV tests:

1. Initial examination of the patient by a TB specialist for the presence of visible symptoms of TB. Informing the patient about possible infection.
2. The patient must carefully monitor his health every day and, if the first signs of tuberculosis are detected, contact his doctor.
3. When registering, X-ray diagnostics of the chest area is performed every six months.
4. Carrying out a tuberculin test.
5. The doctor, if hyperergy or an unusual reaction to tuberculin is detected, taking into account the stage of HIV infection, is obliged to prescribe treatment with anti-tuberculosis medications.
6. When sputum appears, studies of this biological substance are prescribed.
7. If the patient’s health worsens, urgent hospitalization is required.

Effective treatment methods

One of the diseases considered is treated in a standard established way, but when both pathologies are combined, the therapy becomes much more complicated. Having discovered HIV, the doctor prescribes anticonvulsants, antifungal drugs, Rifabutin and Rifampicin.

It is important that all medications are prescribed only by a highly specialized doctor; self-medication can lead to dire consequences. You shouldn’t believe grandmothers that a miraculous centipede bath can save you from this terrible disease. The drugs can be taken at a time; in some cases, Rifampicin can be replaced.

In many ways, the outcome of therapy depends on the competence of the specialist, since the treatment of a tandem of two pathologies is quite aggressive, so it is necessary to develop the correct therapeutic plan that will not harm the compromised health.

Like any treatment, this therapy has its side effects. When using Isoniazid, pain in the head begins, and the nervous system is subjected to a strong blow. There is a risk of drug-induced hepatitis, but only after prolonged use of Rifampicin or Pyrazinamide.

HIV and resistant tuberculosis are treated in a hospital, in an isolated room, until the test results show positive dynamics. In the case of a multi-resistant form, Amikacin, Capriomycin, Kanamecin, Clarithromycin are prescribed.

Cure one disease does not mean getting rid of it completely. There is a high probability of relapse, so treatment must be comprehensive, and in some cases aggressive (for example, abdominal tuberculosis of an HIV-infected person).

As for preventive measures, a clear action plan is also required. Prevention is carried out in several stages, the first is chemoprophylaxis of tuberculosis in HIV-infected people. Further, the impact is reduced, everything comes down to simple examinations by a phthisiatrician.

To date, several methods of curing tuberculosis in combination with HIV infection have been identified. However, if the disease develops in a latent form, it is very difficult to control it.

It should be understood that if tuberculosis develops alone, it is easier to cope with it. However, it is complicated by HIV infection, so therapy must be quite aggressive and high-quality. HIV and tuberculosis can be cured, you just need to notice the disease in time.

Tuberculosis in HIV-infected patients is quite common. This combination of infections can be extremely dangerous for a weakened body. The success of treatment and further prognosis depend on the correct and timely diagnosis of this combined pathology.

HIV and tuberculosis are two diseases that affect the same cells in the body. The immunodeficiency virus invades T-lymphocytes, which are responsible for cellular immunity. However, they provide protection against mycobacteria, and this explains why tuberculosis develops so easily in HIV.

As T cell levels decline, the likelihood of co-infection increases. Currently, tuberculosis occurs in 50–55% of HIV-infected people, according to various sources. The incidence depends on the immune status of the patient.

Moreover, damage by mycobacteria is considered the leading cause of mortality in immunocompromised patients.

If we consider the structure of mortality from secondary diseases associated with HIV, it is tuberculosis that occupies a lowly first place.

Mechanism of the pathological process

When the tuberculosis pathogen enters the body, the latter tries to destroy it. The process of destroying a foreign cell is called phagocytosis. It is provided by cells of the immune system - T-lymphocytes. Their role in anti-tuberculosis immunity is key.

When infected with HIV, T-cells cannot produce the required amount of special antibodies, interferon and other substances, and thus the body’s ability to resist mycobacteria decreases, and the chances of getting sick increase.

In addition, the immunodeficiency virus inhibits the activity of other defenders - macrophages, polynuclear cells, monocytes - and disrupts their movement into the lung area. Namely, they are the favorite localization site for mycobacteria.

Alertness

Considering the frequent combination of tuberculosis and HIV infection, caution regarding this combination must necessarily be present in the practice of a therapist, infectious disease specialist, phthisiatrician and immunologist. The possibility of damage to the body by mycobacteria must be taken into account in the diagnostic search. And although other pathologies also occur in persons with immune defects, it is necessary to carefully conduct an examination so as not to miss tuberculosis, since this significantly worsens the prognosis for the patient’s health and life.

It is important to know that mycobacteria can infect the body of an HIV-infected patient, regardless of what stage of the disease he is at. The age of the patient also does not matter. Even children with HIV infection can easily become infected with TB.

However, the severity of the pathology and clinical manifestations change with a decrease in immunity. Thus, when the number of special cells (CD4 + lymphocytes) decreases, the course of tuberculosis becomes atypical.

CD4+ lymphocyte count > 500

Tuberculosis in HIV infection with a high level of CD4+ lymphocytes (500 per μl and above) occurs with a typical clinical picture.

At the same time, it is characterized by the following features:

1. Tuberculosis is usually pulmonary. Extrapulmonary forms, as well as a generalized process, are rare.
2. The intrathoracic lymph nodes are practically not involved in the pathological process. However, if we compare damage to the lymph nodes in healthy individuals and patients with immunodeficiency, this pathology is more common in the latter.
3. A specific process is usually limited to only certain segments. The first, second, sixth and tenth ones are most often affected.
4. The disease develops gradually, with characteristic symptoms. The severity of the condition corresponds to the extent of tuberculosis lesions.

At this stage, the disease is often detected during an annual fluorographic examination.

CD4+ lymphocyte level 350–500

As immunodeficiency progresses, the level of CD4+ lymphocytes decreases. When their content is in the range of 350–500 cells per μl, the course of tuberculosis changes. The pathology still retains its typical symptoms and course, but the process is spreading.

This stage of HIV infection is characterized by the involvement of serous membranes in a specific infectious process. In such patients, along with the usual pulmonary form, tuberculous pleurisy often develops, which seriously aggravates the course of the disease.

CD4+ lymphocyte level<350

When the level of CD4+ lymphocytes falls below 350 cells per microliter, the course of tuberculosis becomes atypical.

This form of the disease is characterized by:

• Severe fever (up to 39° and above).
• Progressive loss of body weight.
• Night sweats.
• Severe weakness.
• The cough may not be severe, almost always dry, without sputum production.
• Hemoptysis is uncharacteristic.

With this level of immunity, the prognosis for the disease is unfavorable.

AIDS stage

Many patients are interested in the question of how the combination of AIDS and tuberculosis manifests itself. Unfortunately, in this situation one usually cannot hope for a favorable outcome.

AIDS is a terminal stage of the disease in which any antiretroviral treatment has little effect. It occurs when the level of CD4+ lymphocytes decreases to less than 200 cells per μl.

How long do patients with acquired immunodeficiency syndrome live? In this regard, no doctor will give definite prognoses, but according to numerous observations, without therapy, life expectancy is no more than three years.

But more often than not, patients manage to live only 1–2 years. If tuberculosis is added, the prognosis is much worse.

Diagnostics

• Low grade fever or fever.
• Cough – dry or wet.
• Weight loss.
• Night sweats.

These signs also occur in other diseases, but first of all they should alert the doctor to infection with mycobacteria.

In people with HIV infection, these nonspecific symptoms are considered screening symptoms. If the patient has at least one manifestation, he is recommended to undergo a detailed examination and, if necessary, appropriate treatment.

The earlier this category of patients is diagnosed, the higher their chances of survival.

However, the diagnosis of tuberculosis in HIV-infected people has its own characteristics.

Diagnostic features

HIV infection and acquired immunodeficiency syndrome affect the course of the disease. Therefore, in the diagnosis of pulmonary lesions it is necessary to take these features into account. Among them, the most important are:

• Any changes in the lungs at the AIDS stage should be considered as possible tuberculosis due to the atypical course of the disease.
• In the absence of confirmation, antibacterial drugs with anti-tuberculosis action (rifampicin, kanamycin, streptomycin) are not used. They are quite toxic and can also provoke the development of resistance in mycobacteria.
• Trial therapy for unconfirmed tuberculous changes in the lungs is carried out only with nonspecific drugs.
• If infection with mycobacteria is suspected, the sputum must be examined microscopically using the Ziehl-Neelsen method, in addition, it is inoculated on special nutrient media.
• Rapid diagnostic options are used (PCR or BACTEC).

Of the instrumental examinations, the following methods are most often used:

• Radiography.
• CT scan.
• Bronchoscopy.
• Lung biopsy – transthoracic or transbronchial.
• Pleural biopsy.

Diagnosis based on CD4+ lymphocyte count< 350

Typically, the first test for a patient with HIV and suspected pulmonary tuberculosis is radiography. In a situation where the number of CD4+ lymphocytes decreases significantly, the x-ray picture also changes.

Patients will be determined:

• All parts of the lungs are affected equally.
• Predominant involvement of intrathoracic lymph nodes in the process.
• Specific pleurisy and pericarditis.
• Disseminated forms of the disease.
• Less frequent detection of destructive forms of the infectious process.
• Rapid progression of the disease according to radiographs.

Inconsistency between clinical manifestations and radiological changes.

At the AIDS stage, on the contrary, destructive forms will occur very often due to the extensive colonization of the lungs with mycobacteria. However, with severe immunodeficiency, due to the lack of body resistance, there may be no changes at all on the x-ray.

Tuberculosis and HIV in children

Currently, many children are infected with HIV, and their number is growing daily. At a young age, the combination of two infections is more severe than in adults. It is impossible to predict how serious the consequences will be. However, babies die from this combination six times more often. That is why tuberculosis must be excluded in all young patients with HIV. However, the opposite statement is also true.

Tuberculosis screening in HIV-infected children is carried out in the same way as healthy ones. When collecting anamnesis, contacts with tuberculosis patients are checked, and a thorough clinical examination is carried out. An annual Mantoux test (or an alternative diagnostic method) and chest x-ray are mandatory. Identifying tuberculosis in children at an early stage can improve the effectiveness of treatment and increase the chances of survival.

Extrapulmonary tuberculosis

If in people with normal immunity extrapulmonary tuberculosis occurs in 10–20% of cases, then with concomitant HIV infection the proportion of this form can reach 70%.

However, sometimes, according to statistics, the proportion of extrapulmonary localization of the pathological focus is significantly lower. But this is more likely due to an insufficient level of diagnosis than a low incidence.

In people with immune defects, mycobacteria most often affect the following organs and systems:

• Genitourinary.
• Joints, bones, spine.
• Central nervous system.
• Lymph nodes of various locations - peripheral and intrathoracic, sometimes mesenteric.

However, most often extrapulmonary tuberculosis affects the pleura with the development of specific pleurisy.

Course of the extrapulmonary form

For the course of tuberculosis (extrapulmonary form) during HIV infection, the most characteristic are two main syndromes - intoxication and local changes.

The first is characterized by fever and sweating, weight loss, and weakness.

Local changes are determined by the organ that is affected by mycobacteria. For example, with abdominal tuberculosis affecting the mesenteric lymph nodes, peritoneum, and intestines, the first complaint of patients will be pain in the abdominal area.

It can be chronic, dull or sharp, cramping. Often tuberculous mesadenitis simulates the clinical picture of an acute abdomen. Also, patients will notice a disturbance in appetite, up to its absence, and indigestion.

Diagnosis of the extrapulmonary form, in addition to conventional methods, is supplemented by the following studies:

• Computed tomography of the abdominal cavity and chest organs. Contrast is used to detail formations in these areas.
• Magnetic resonance imaging. Most often it is prescribed for suspected tuberculosis of the central nervous system.
• Ultrasound examination of lymph nodes.

In addition, endoscopic diagnostic methods are widely used for extrapulmonary forms:

• hysteroscopy;
• arthroscopy;
• laparoscopy;
• cystoscopy;
• bronchoscopy;
• colonoscopy.

Prevention

Prevention of tuberculosis in HIV infection is of great practical importance. First of all, if you are immunodeficient, you should avoid contact with people who have a confirmed diagnosis of tuberculosis, since the likelihood of infection in them is too high. But, unfortunately, this disease can be found anywhere and in any person.

A high level of CD4+ lymphocytes is more capable of protecting against mycobacteria, so antiretroviral therapy and maintaining immunity at the proper level are the best prevention.

It also includes timely examination of patients, even if they have no signs of the disease. After all, the sooner tuberculosis is detected, the sooner treatment will begin.

Sometimes it is not the active form of the disease that is detected, but tuberculosis infection. And doctors prescribe chemoprophylaxis to prevent the spread of the process. In patients with immunodeficiency it is mandatory.

Treatment

The combination of anti-tuberculosis treatment and antiretroviral therapy can be difficult for patients to tolerate, since it involves the simultaneous administration of a large number of rather toxic drugs. That is why treatment of tuberculosis, as a more rapidly progressing disease, is a priority.

If possible, antiretroviral therapy is delayed for some time. However, it significantly reduces mortality among patients with underlying infections. And, if there are serious indications, both types of treatment are prescribed simultaneously, regardless of side effects. However, their probability must be taken into account when selecting a combination of drugs.

Anti-tuberculosis therapy is divided into two stages. The first is called intensive and lasts 2 months, after which its effectiveness is reviewed. If the results are good, the patient is transferred to maintenance therapy, which continues for another 4 months. If necessary, the course of treatment is prolonged.

Monitoring the intake of anti-tuberculosis drugs by patients is very important. Without it, the quality of treatment often suffers.

HIV infection and tuberculosis are an extremely dangerous combination. However, with proper treatment, patients can maintain normal life expectancy and a decent quality of life.

The number of cases is growing every year, and the situation with tuberculosis in Russia remains unfavorable. This disease poses a particular threat due to the emergence of drug-resistant forms, as well as the spread of previously unknown forms. Increasingly, doctors have to deal with a combination of tuberculosis and HIV infection. These two socially determined diseases have much in common, complementing and reinforcing each other.

Today, we are talking about the dangers of such a combination with the Deputy Chief Physician for the Medical Department of the Chelyabinsk Regional Anti-TB Dispensary, a TB doctor of the highest category, Candidate of Medical Sciences Valentina Okhtyarkina.

— Valentina Vyacheslavovna, why should AIDS patients be considered as potential tuberculosis patients?

— The fact is that tuberculosis loves immunodeficiency states, when the body is not protected. Immunodeficiency can be caused by various factors - social, medical. The human immunodeficiency virus leads to the death of immune cells, causing the development of acquired immunodeficiency syndrome. Therefore, these patients are considered to be at risk for tuberculosis.

In our region, most of these patients lived to a state of immunodeficiency, what is called acquired immunodeficiency syndrome (AIDS). And the most common disease they have is tuberculosis. It is 2-3 years ahead of all AIDS-indicative diseases, this is global statistics. In Russia, tuberculosis is the leading cause of death in patients with HIV infection. And this is a new huge risk group for us.

— That is, these people can easily become infected with tuberculosis, and their own disease can cause tuberculosis to manifest itself?

“Indeed, a patient with HIV infection is more at risk of becoming infected when in contact with a patient with tuberculosis due to his reduced immune status. Immunity for tuberculosis is non-sterile, that is, it is maintained by the constant presence of Mycobacterium tuberculosis in the body. Most of the adult population in our country is infected with it, but we are not sick. We do not get tuberculosis because we have a normal immune status. But as soon as it begins to decline for various reasons, the risk of developing tuberculosis increases sharply. This is the main reason for the increased incidence of tuberculosis in patients with HIV infection.

— Is tuberculosis different from the usual in HIV-infected patients?

— Yes, there are significant differences in tuberculosis in the later stages of HIV infection, or the so-called “AIDS-associated tuberculosis.” Firstly, these are the clinical manifestations of the disease. If with ordinary tuberculosis complaints of weakness, sweating, cough, and possibly hemoptysis predominate, and all these symptoms increase gradually, then in the later stages of HIV infection the clinical picture is very acute. Patients develop a fever with a temperature of 38 - 39 0 C, they lose weight by 10, 20, sometimes 30 kilograms, some patients experience enlargement of the axillary or cervical lymph nodes, and hemoptysis is extremely rare. Secondly, there are differences in the radiological manifestations of tuberculosis. Thirdly, very often there is a combination of pulmonary tuberculosis with tuberculous damage to other organs (lymph nodes, bones, joints, damage to the nervous system) or other secondary diseases in AIDS.

The most unfavorable thing is that even with such a clinic, radiological manifestations of tuberculosis may be minimal or may not exist at all for a very long time. And if a patient turns to a local physician, and at the same time hides the fact that he has HIV, it is extremely difficult to identify tuberculosis. Usually these patients are admitted to hospitals in very serious condition. But even there they manage to hide their HIV status.

— It turns out that diagnostics requires a new approach?

— The scope of the patient’s examination is determined by the doctor, so doctors of all specialties need to know about these features, including the radiological signs of the disease.

— Is additional training required for this?

“We, together with the regional Center for the Prevention and Control of AIDS, have been carrying out this work for several years. At first these were joint seminars for TB specialists and infectious disease specialists, and we hear each other very well. Today everyone understands that this problem cannot be concentrated only between these two specialties, and we are actively involving all primary contact doctors from hospitals and clinics in this problem.

Last October, we held a large conference on this topic, where we invited deputy chief physicians for the medical department of district and large multidisciplinary hospitals to highlight the problem and develop a definite position on the examination and treatment of such patients.

— Valentina Vyacheslavovna, you said that HIV-infected people sometimes hide their status even when going to the hospital. This is a danger for others, but also for themselves. Or when an HIV-infected patient has a generalized form of tuberculosis, he no longer cares, he is doomed?

- No, this does not mean at all that a person is doomed. On the contrary, there is a peculiarity that in the later stages of HIV infection, drugs penetrate the body better and have an effect faster. And the drugs now are very good. Therefore, if a person knows that he has HIV infection, it is necessary to promptly contact the regional Center for the Prevention and Control of AIDS to infectious disease doctors who are directly involved in this disease.

Under no circumstances should you hide your HIV status, because in this case the examination follows a different algorithm, it is delayed, and the true diagnosis of tuberculosis can be arrived at very late. When patients promptly contact the Center for Prevention and Control of AIDS, they are referred for a consultation with a phthisiatrician, and then, if tuberculosis is detected, to an anti-tuberculosis dispensary, the prognosis for recovery is quite optimistic.

— Do we have new diagnostic methods for detecting tuberculosis in patients with late stage HIV?

— Currently, our region has a fairly updated fleet of X-ray and laboratory equipment, which plays an important role in the diagnosis of tuberculosis. Computed tomography has become more accessible. PCR diagnostics of tuberculosis has appeared. As for drugs to treat the disease, we are provided with them in sufficient quantities. We have everything we need to treat tuberculosis today, so it is important that those patients who need it reach us as quickly as possible, regardless of whether the patient has HIV infection or not.

I urge everyone to regularly (preferably at least once a year) undergo fluorography, and, if necessary, undergo further examination. All TB doctors are caring people, and they will definitely try to help.

Identification of a patient with widespread and rapidly developing tuberculosis is a signal that targeted testing for HIV infection will be required. Patients with AIDS should be considered as potentially having any form of lung disease. Tuberculosis and HIV require the earliest possible start of a recovery course and long-term prevention.

Epidemic processes associated with HIV infection have made and are continuously making significant changes in the epidemiological background of tuberculosis. The main impact of HIV infection is the rate of development of clinically expressed tuberculosis in people previously infected with MVT or who have developed AIDS. Tuberculosis and HIV infection can be combined in several variations, the treatment of which is carried out in different ways:

• initial infection with tuberculosis in HIV-infected patients;
• synchronous encounter with HIV infection and tuberculosis;
• formation of a tuberculosis algorithm due to the occurrence of immune deficiency during HIV infection (this may be AIDS).

People infected with both tuberculosis and HIV are especially at increased risk of developing a pathological process.

They have an annual tendency to develop tuberculosis, which is 10%. For other members of the population, this probability does not exceed 5% throughout their entire life course, and treatment may not be necessary.

The main thing about pathology

HIV infection and AIDS significantly affect the state of immune reactivity in tuberculous lesions of the lungs and other systems. Within the framework of the presented process, relationships may change in the process of immune activation at the cellular level, differentiation of macrophages and the formation of special tissue of a granulation nature are identified.

In accordance with this, a more frequent formation of tuberculous lesions in HIV-infected people (the same is true for those infected with AIDS) can be observed in several cases. This may occur due to a decrease in the degree of resistance to initial or secondary infection with MBT (an exogenous route of infection, the treatment of which is most problematic). This can be influenced by the reactivation of old changes after tuberculosis, the worsening of anti-tuberculosis immunity (reactivation based on endogenous characteristics).

Symptoms of the condition

The main manifestations of tuberculosis due to HIV infection should be considered asthenia, permanent or intermittent fever. Prolonged coughing, a significant decrease in body weight, bouts of diarrhea and an increase in the size of the lymph nodes may occur. Most often, the latest changes affect the cervical and axillary nodes, and to the least extent, the inguinal nodes. It is important to pay attention to the fact that the lymph nodes acquire a dense consistency, become lumpy and practically do not move during palpation.

The severity of symptoms of tuberculosis in HIV-infected and AIDS patients is directly dependent on the nature and suppression of cellular immunity. In order to facilitate future treatment and minimize the likelihood of complications, it is necessary to have complete information about additional symptoms.

More about symptoms

More obvious clinical symptoms are identified in patients whose tuberculosis has developed due to HIV infection.

It should be noted that:

• this happens less frequently than in patients with tuberculosis, who subsequently became infected with HIV and faced such a terrible disease as AIDS;
• symptoms associated with tuberculosis, when the lymphocyte ratio remains sufficiently high, may remain the most characteristic and cannot be differentiated in any way from the manifestations and X-ray findings in HIV-negative patients;
• at the last stage, standard manifestations associated with the pulmonary form of tuberculosis predominate in patients.

A prerequisite before starting treatment and starting prevention is to carry out a diagnostic examination. The patient’s health status and other vital processes depend on its timeliness and correctness.

Diagnostic measures

Identification of tuberculosis in HIV-infected people and those who have developed AIDS is carried out based on conventional methods. They refer to a mandatory clinical examination and consist of a detailed study of the patient’s complaints and medical history. The next stage is an objective examination, blood and urine testing for the presence of problematic components.

Next, radiography is carried out, in which the chest organs are examined, and there is a need for repeated examination of sputum using a microscope and its culture for the presence of nutrient media. An intra-epidermal Mantoux test, ELISA of antibodies and tuberculosis-type antigens are assessed.

Difficulties in diagnosing the tuberculosis condition arise at the stage of secondary symptoms, in particular with AIDS. The presence at the presented stage of disseminated and extrapulmonary forms with a sudden decrease in the number of situations of decay of pulmonary tissue reduces the number of patients. At the same time, MBTs, the treatment of which is most problematic, are identified in their sputum during examination with a microscope (using the Ziehl-Neelsen method) and as part of culture.

Rehabilitation course

Chemotherapy for tuberculous lesions that have spread to the respiratory system in HIV-infected people is the most effective. It should be noted that:

• the standard aspect of therapy for patients with tuberculosis and AIDS should be considered the simultaneous use of a certain amount of antiretroviral drugs;
• the use of similar drugs is a mandatory element that is necessary when treating tuberculosis with long-term forms of infection;
• the total duration of the recovery course is identified by the moment the release of bacteria stops and the normalization of all processes in the pulmonary area.

Considering the likelihood of low effectiveness of combining “spare” drugs and the possibility of relapses of tuberculosis lesions (provoked by multiple and stable MBT processes), therapy with chemically active drugs is carried out for at least 18-22 months. In order for treatment to be 100% effective, correct and complete prevention is required.

Preventive actions

When HIV and tuberculosis are connected, special prevention is required. It cannot be limited only to proper nutrition and a special diet, although this measure is mandatory.

In order to achieve success in the recovery process, you should take vitamin and mineral complexes, eat the maximum amount of seasonal vegetables and fruits, berries.

It is important to completely eliminate bad habits and lead a healthy lifestyle. This means daily walking, morning exercises and contrast showers. In some cases, it is permissible to resort to hardening the body. To monitor your health status and the degree of success of treatment, it is necessary to undergo diagnostic examinations and consultations with a pulmonologist and phthisiatrician.

It is important to pay attention to the fact that preventive measures, like treatment, must be long-term. We are not talking about 12-16 months, but about two or more years. With such an integrated approach, which must be combined with a rehabilitation course, success will be achieved. However, one should not discount the danger of HIV and the impossibility of stopping the presented process.

Tuberculosis in HIV-infected people is undoubtedly a dangerous process. However, subject to early diagnosis and correct recovery course, it will be possible to stop it. This will avoid complications and other critical consequences, the treatment of which is problematic in the long-term nature of the course.