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6 V. SIVARAMAN ETAL Clinical Aspects Pitchenick and Rubinson 15 have made the following detailed observations on 23 adult patients who had culture proved tuberculosis and acquired immuno-deficiency syndrome: (1) Chest radiographs resemble frequently the pattern of primary tuberculosis, i.e. hilar or mediastinal adenopathy with or without cavitation; pulmonary infiltrates are located with approximately equal frequency in the upper and lower lung fields; sputum cultures for M. tuberculosis are frequently positive; pleural effusions are infrequent and small while extrathoracic (especially lymphatic) tuberculosis is very common, probably part of a generalised lymphatic tuberculosis. (2) Patients may present with or develop miliary TB while under observation. (3) Other concurrent pulmonary infections (e.g. Pneumocystis carinii pneumonia) are common and confound the radiographic diagnosis of pulmonary tuberculosis. In this situation, rapidly changing pulmonary infiltrates suggest a non tuberculous infection and hilar or mediastinal adenopathy may serve as a clue to the co-existence of tuberculosis. (4) Patients may have positive sputum cultures for M. tuberculosis or active extra thoracic or disseminated tuberculosis even though the chest radiographs are normal. (5) Despite the immuno-suppressed state, the chest radiographic abnormalities clear within months of starting anti-tuberculosis drug therapy. (6) Patients with AIDS and mycobacterial disease, frequently, do not show the typical granulomatous tissue reaction. This may explain the absence of pulmonary cavitation and rapid radiographic clearing of tuberculous infiltrates after drug therapy without evidence of scaring. The presence of tissue granulomas may denote a better state of body immune defences. Two closely related non-chromogenic mycobacteria (Runyon's group III)-M. avium and M intracellulare grouped together as Mycobacterium avium complex (MAC) have been isolated from patients with HIV infection in the United States and other developed countries, more often than other mycobacteria including the more virulent M. tuberculosis, although the reverse is true in Central Africa and other developing countries 4 ' However, the clinical significance of the recovery of these mycobacteria from the lungs alone remains uncertain, while the identification of these organisms in lymphnodes, bone marrow or blood is persuasive evidence of the presence of disseminated disease. But the clinical relevance of disseminated disease with M avium complex in patients with AIDS is not clear. The currently available anti-mycobacterial agents do not, usually, produce clinical improvement or microbiologic cure. Therapeutic Aspects The standard anti-tuberculosis drugs are extremely effective in TB patients with HIV infection. The recommended regimen for treating tuberculosis in HIV infected adult patients is Isoniazid, Rifampicin and Pyrazinamide but Ethambutol may also be used if Isoniazid resistance is suspected. The CDC and the American Thoracic Society have recommended that treatment be given for at least six months beyond the conversion of sputum culture to negative in patients with HIV infection and pulmonary tuberculosis 16 Adverse reactions to anti-tuberculosis medicaments necessitating a change in therapy occurred in 25% of Chaisson's patients 8 . Mortality in patients with tuberculosis and AIDS is high in the different reported series : the median survival from the time of tuberculosis diagnosis was 7.4 months and from the time of AIDS diagnosis 8.1 months in Chaisson's series. The cause of death was almost always AIDS, not tuberculosis. Efforts to treat HIV infection and AIDS have been directed towards inhibition of virus replication and restoration or stimulation of the impaired immune function 17 - Restoration of immunity has been attempted by bone marrow transplantation or lymphocyte transfusion and by lymphokine administration. Immune-stimulatory drug therapy has also been proposed for increasing immune functions in HIV infected persons. Preliminary reports on isoprinosine in patients with generalised lymphadenopathy or the AIDS related complex have shown a transient improvement in the natural killer cell functions 18
HIV AND TUBERCULOSIS 7 without consistent clinical alleviation. Further, the use of cyclosporin, despite its obvious potential hazards, and intravenous gammaglobulin has also been tried. Further trials of antibody preparations may be expected 19 The Effect of HIV Infection on Tuberculosis Programmes Besides the possible increase in the number of tuberculosis patients, to receive services, important qualitative changes in the tuberculosis services can be anticipated in the HIV/AIDS era. The new problems to be tackled include the following 10 : 1. HIV positive persons are frequently tuberculin negative, lowering the sensitivity of this tool. 2.. The clinical and radiographic pictures of tuberculosis are different from what is normally seen. 3. There are reports of more frequent relapses with the use of conventional chemotherapy and CDC has made different recommendations for effective treatment. 4. The concern about the use of BCG, following reports of severe local reactions and possible dissemination has led to a modification in the WHO EPI recommendation favouring its exclusion in symptomatic HIV infected children. 5. The transmission of HIV may occur among TB patients through the use of inadequately sterilized syringes for Streptomycin injections. The joint WHO/IUATLD working group on HIV infection and tuberculosis 20 has recommended that when sterility of needles and syringes cannot be ensured, an entirely oral regimen should be used. The working group has further recommended that in countries where the national TB programme strategies include chemoprophylaxis, dual infection with HIV and M. tuberculosis should be considered as an indication for chemoprophylaxis. So far as India is concerned, pessimism on account of AIDS may not be warranted as the seroprevalence rate even in high risk groups is comparatively low. Nevertheless, vigilance and prompt action by clinicians and programme planners is called for. Acknowledgement We are grateful to Director, JIPMER and Director, Health and Family Welfare Services, Government of Pondicherry for permission to publish this paper. Shri Ram Mohan's assistance in getting the computer print outs is also acknowledged. References 1. Barre, Sinoussi F., Chermann J.C, Rey F et al. Isolation of a T lymphotropic retrovirus from a patient at risk for acquired immuno deficiency syndrome (AIDS), Science; 1983, 220, 868. 2. Popovi C.M, Sarangadharan M.D,, Read E, Gallo R.C. Detection, isolation and continuous production of cytopathic retroviruses (HTLV- III) from patients with AIDS and pre AIDS. Science, 1984, 224 ? 497. 3. Prignot J, and Sonnet. AIDS, Tuberculosis and mycobacteriosis. Bull. IUATLD; 1987, 62, 7. 4. Murray J.F and Mills J. Pulmonary infectious complications of Human immuno deficiency virus infection; Am. Rev. Respir. Dis., 1990,141, 1356, 5. Centers for Disease Control—Tuberculosis final data-United States 1986 MMWR 1988, 36, 817. 6. Pitchenick A.E., Cole C, Russel B. 5 Fischl, M.S., Spira J and Snider D,E, Jr. Tuberculosis, atypical mycobacteriosis and the acquired immuno- deficiency syndrome among Haitian and non Haitian patients in South Florida. Ann. Intern. Med., 1984, 101, 641. 7. Louis E.E., Ricel B. ; and Hizman R.S. Tuberculosis in non Haitian patients with acquired immuno deficiency syndrome. Chest; 1986, 90, 542. 8. Chaisson R.E., Sheeter G.E., Thever C.P., Rutherford G.W., Echenberg D.F., and Hopeweil P.C. Tuberculosis in patients with the acquired immuno deficiency syndrome, clinical features, responses to therapy and survival. Am. Rev. Respir. Dis.; 1986, 136, 570. 9. Mann J.M. Chin J, Piot P., Quinn T. The international epidemiology of AIDS Sci. Am. 1988, 8, 82. 10. Slutkin G. Leowski J and Mann J. The effects of the AIDS epidemic on the tuberculosis problems and tuberculosis programmes. Bull. IUATLTD; 1988, 63, 21.
Page 1 and 2: The Indian Journal of Tuberculosis
Page 3 and 4: Leading Article Ind. J. Tub., 2992,
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Page 11 and 12: SCC AND EFFICIENCY VARIABLES IN DIS
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NEWS AND NOTES 61 It was also decid
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INDIAN JOURNAL OF TUBERCULOSIS 63 d
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