HIV/TB Co infection: A HIV/TB Co infection: A case presentationcase presentation

Dr Farouk Muhammad Dayyab (farouqmuhd@yahoo.com) Government House Clinic Jalingo18th February, 2009

Synopsis Synopsis HistoryExaminationAssessmentManagement planInvestigation resultsAnalysis of the HistoryAnalysis of Examination findingsComments on the management

planConclusionReference

HistoryHistoryI am presenting Mr M.K. Unit No

18210, a 32yr old male muslim applicant from Magami quarters who presented on the 24th september 2007 at this clinic with 1 week history of fever, cough and diarrhoea. These symptoms have been on and off prior to that episode.

His wife died of chronic illness.

ExaminationExaminationA chronically ill looking young

man wasted afebrile, anicteric, acyanosed not dehydrated and no pedal edema. No peripheral lymphadenopathy.

AssessmentAssessmentPTB R/O RVI

Management PlanManagement PlanPretest councelling for RVSCD4 cell count, E/U/CR, LFTSputum AFB X 3, CXRTabs Ciprofloxacin, Metronidazole

and Fansidar.

Investigation resultsInvestigation resultsSeropositiveAFB X 3 ( - ve )CXR- SuggestiveCD4 count – 60 PCV – 34%LFT – normalU/E/Cr – normal

PlanPlanCommence on DOTS and HAARTTo Substitute Nevirapine with

Efavirenz

Analysis of HistoryAnalysis of HistoryMissing AspectsMissing AspectsSystemic reviewPast Medical HistoryDrug History*Family and Social History

Why Systemic Review in this Why Systemic Review in this HIV/TB Patient?HIV/TB Patient?HIV is a Multi-Systemic DiseaseHIV/TB Patients are more likely to

have extra-pulmonary Tuberculosis.....Extrapulmonary TB occurs in 70% of HIV related TB cases when CD4 count is less than 100.(Francis J Curry National TB centre USA)

Why Systemic Review in this Why Systemic Review in this HIV/TB Patient? HIV/TB Patient? the chestthe chestHistory of cough, hemoptysis,

dyspnoea, chest pain, stridor and hoarseness of the voice

BECAUSE:1.PTB2.RVI: PCP, CMV Pneumonia, Fungal

chest infections(Histoplasmosis, aspergillosis, blastomycosis), Kaposis sarcoma of the lungs, lymphoid interstitial pneumonitis, lymphomas

Why Systemic Review in this Why Systemic Review in this HIV/TB Patient? HIV/TB Patient? the gitthe gitHistory of abdominal pain, nausea, vomitting,

loss of appetite, weight loss, difficulty swallowing, haematemesis, abdominal distention, constipation, diarrhoea, anorexia, regurgitation, jaundice, haematokisea, melaena, anal protrusion, hiccups, steatorrhoea, pruritus.

BECAUSE:1.TB: Abdominal TB(TB Ileitis, peritonitis and

adenitis)2.RVI:Ascending cholangitis, chronic diarrhoea

from opportunistic infections(Cryptosporidium, isospora belli, microsporidium),HIV enteropathy, giardia lamblia,E. Histolitica, E. Fragilis, Shigella, Adeno virus and rota virus, Anorectal ca., fistula in ano, anal fissures.

Why Systemic Review in this Why Systemic Review in this HIV/TB Patient? HIV/TB Patient? the cvsthe cvsHistory of dyspnoea, PND, orthopnoea,

cough,hemoptysis, fatique, syncopal attack, intermittent claudication, pedal edema, symptoms of pericarditis(pain behind the left sternal border aggravated by sneezing, swallowing and deep breathing)

BECAUSE:1.TB: TB pericarditis2.RVI: HIV cardiomyopathy, vasculitis.

Why Systemic Review in this Why Systemic Review in this HIV/TB Patient? HIV/TB Patient? the cnsthe cnsHistory of headache, tremors, nervousness,

excitability, fainting attacks, pits, irrational behaviour, paralysis(hemi/para paresis or phlegia), sensory or hearing disturbances, change in vision, smell or taste.

BECAUSE:1.TB: TB Meningitis2.RVI: Meningoenchephalitis, cranial nerve

palsies, peripheral neuropathy, tubercular enchephalitis, cryptococcal meningitis, AIDS-related dementia, progressive multifocal leukoenchephalopathy, seizure disorders, hemiphlegias and paraphlegias.

Why Systemic Review in this Why Systemic Review in this HIV/TB Patient? HIV/TB Patient? the gutthe gutHistory of loin pain, suprapubic pain,

frequency, urgency or hesitency, dysuria, oliguria, anuria, polyuria, hematuria, urethral discharge, facial swelling.

BECAUSE:1.TB: Urogenital TB(urethritis, cystitis,

etc)2.RVI: HIV nephropathy, Penile ca.,

Genital wart, worsening of STI especially syphyllis.

Why Systemic Review in this Why Systemic Review in this HIV/TB Patient? HIV/TB Patient? the mssthe mssHistory of muscle, joint, or bone

pain, swelling or limitation of movement.

BECAUSE:1. TB: Skeletal Tuberculosis, Potts

disease- Tb spondylitis>Gibbus(vertebral collapse)

Why Past Medical History in Why Past Medical History in this HIV/TB Patient? this HIV/TB Patient? BECAUSE:1.Past history of hospital

admissions and blood transfusion.

2.Any history of DM which predisposes to TB

Why Drug History in this Why Drug History in this HIV/TB Patient?HIV/TB Patient?BECAUSE:1.Long term steroid use

predisposed to TB2.To check interactions with HIV/TB

drugs to be given.3.Past history of use of anti TB

drugs

Why Family and Social Why Family and Social History in this HIV/TB History in this HIV/TB Patient?Patient?BECAUSE:1.Sexual history: promiscuity, STIs2.Marital History: Previous and

Present marriages3.Alcohol consumption predisposes

to TB

Analysis of ExaminationAnalysis of Examination Findings Findings?? Findings on chest examination not

recorded despite chest symptoms.Looking for dyspnoea(Normal:14-

16cpm), signs of consolidation(diminished chest expansion,increased tactile fremitus, bronchial breathsounds, crepitations, increased vocal resonance, pleural rub)

Other systems should be examined based on presence of symptoms in them during history taking.

Comments on the Comments on the Management Plan: Management Plan: the the negative sputum AFB in this negative sputum AFB in this HIV/TB PatientHIV/TB PatientSputum AFB detects 60% of all new

TB infections and as few as 20% to 35% in HIV/TB infections. Therefore sputum negativity does not exclude the presence of disease(HIV/TB coinfection: Basic Facts 2007)

Newer tests include: Sputum inoculation, PCR, Broncho alveolar lavage, Blood medium inoculation, Determination of serum Ag and Ab (Pubmed: Probl Tuberk Bolezn 2007(11):225)

Comments on the Comments on the Management Plan: the CXRManagement Plan: the CXRThe details of the chest XR

findings in this patient are not recorded in the case notes but were reported as suggestive of PTB

CXR findings are CD4 lymphocyte count dependent

Comments on the Comments on the Management Plan: the CXRManagement Plan: the CXR1. Early HIV disease CD4>500 cell/ul:

Typical PTB presentation: Upper lobe infilterates, cavitory changes

2. Low CD4 count: Lower lobe infilterates, intrathoracic adenopathy, widespread reticulonodular lesions affecting all zones

3. HIV infected patients with TB may have a normal chest radiograph.(Francis J Curry National TB centre USA)

Comments on the Comments on the Management Plan: Management Plan: the LFT, the LFT, U/E/Cr were within normal limits in this U/E/Cr were within normal limits in this HIV/TB patientHIV/TB patientWhy LFT, U/E/Cr? 1.Metabolism of drugs by the liver2.Excretion of drugs by the kidney3.Both HIV and TB can compromise

liver and kidney function4.To know the baseline to monitor

drug toxicity.

Comments on the Comments on the Management Plan: Use of Management Plan: Use of Ciprofloxacin in this PatientCiprofloxacin in this PatientFlouroquinolone use delays TB

diagnosis in pneumonia patients.(infectious-diseases.jwatch.org)

19% of patients thought to have community acquired pneumonia turn out to have TB.(Kenyan Study)

Use of moxifloxacin alone even for as short as 7 days leads to emergence of resistance to an important 2nd line agent that reduces the duration of treatment of TB to 4 months when used with other antiTB drugs(Pubmed.org)

Comments on the Comments on the Management Plan: Use of Management Plan: Use of Fansidar in this patient.Fansidar in this patient.Monotherapy for malaria is no

longer recommended by WHO and the Federal Ministry of Health.(Training manual for management

of malaria in Nigeria)

Comments on the Comments on the Management Plan: Management Plan: Antihelminths not given to this Antihelminths not given to this HIV/TB patientHIV/TB patientEradication of helminthic

infection decreases HIV plasma viral load in dually infected people in a study conducted in Addis Ababa.(NLM Gateway :A service of

the U.S. National Institutes of Health )

Comments on the Comments on the Management Plan: Management Plan: Patient was Patient was commenced on DOTS and HAART commenced on DOTS and HAART substituting Nevirapine with substituting Nevirapine with EfavirenzEfavirenzAccording to the 2006 WHO recommendations for individuals with HIV/TB coinfection, wether to start DOTS or HAART is based on the CD4 cell count.

4 Categories:1.CD4<200cells/ul2.CD4 200 – 350 cells/ul3.CD4>350 cells/ul4.CD4 not available.

Comments on the Comments on the Management Plan: Management Plan: Patient was Patient was commenced on DOTS and HAART commenced on DOTS and HAART substituting Nevirapine with substituting Nevirapine with EfavirenzEfavirenzCD4<200cells/ul1.Start TB treatment. Start ART as

soon as TB treatment is tolerated.(between 2 weeks and 2 months)

2.EFV regimen is used. EFV is contraindicated in pregnant women or women of child bearing potential without effective contraception.

Comments on the Comments on the Management Plan: Management Plan: Patient was Patient was commenced on DOTS and HAART commenced on DOTS and HAART substituting Nevirapine with substituting Nevirapine with EfavirenzEfavirenzCD4 between 200 – 350 cells/ul1.Start TB treatment for the 2

month intensive phase then commence on ART

2.If patient is severely compromised start the ART earlier.

Comments on the Comments on the Management Plan: Management Plan: Patient was Patient was commenced on DOTS and HAART commenced on DOTS and HAART substituting Nevirapine with substituting Nevirapine with EfavirenzEfavirenzCD4>350 cells/ul1. Start TB treatment, Defer ART.

Comments on the Comments on the Management Plan: Management Plan: Patient was Patient was commenced on DOTS and HAART commenced on DOTS and HAART substituting Nevirapine with substituting Nevirapine with EfavirenzEfavirenzCD4 not available: start TB

treatment, consider ART.(the internet journal of pulmonary medicine.

www.ispub.com)

ConclusionConclusionHIV/TB co infection will continue

to be challenging to both health care providers researchers and patients.

Selected referencesSelected referencesDavidsons principles and practice of

medicine 19th editionHutchisons clinical methods 21st editionTraining manual for management of

malaria in nigeriaOxford handbook of clinical medicineFrancis J Curry National TB centre USA

www.nationaltbcentre.eduHIV/TB coinfection Basic Facts 2007Pubmed: probl Tuberk Bolezn 2007(11):225The internet journal of pulmonary

medicine. www.ispub.comNLM Gateway :A service of the U.S.

National Institutes of Health

Thankyou for listening.Thankyou for listening.