Increased recurrence of tuberculosis in HIV-1-infected patients in Kenya

doi:10.1016/0140-6736(93)91474-Z

The Lancet

Volume 342, Issue 8867, 7 August 1993, Pages 332-337

https://doi.org/10.1016/0140-6736(93)91474-Z Get rights and content

Abstract

There is evidence that in human immunodeficiency virus 1 (HIV-1) infected patients with tuberculosis the rate of recurrence of tuberculosis is increased in those patients treated with a standard thiacetazone-containing regimen. To assess the impact of HIV-1 on tuberculosis in Kenya, patients with tuberculosis were studied prospectively. After treatment with either a standard thiacetazone plus isoniazid regimen or a short-course thiacetazone-containing regimen, overall recurrence rate of tuberculosis was 34 times greater in 58 HIV-1-positive patients than in 138 HIV-1-negative patients (adjusted rate ratio 33·8, 95% Cl 4·3-264). Recurrence in the HIV-1-positive group was strongly associated with a cutaneous hypersensitivity reaction due to thiacetazone during initial treatment (rate ratio 13·2, 95% Cl 3·1-56·2). In all patients with a cutaneous hypersensitivity reaction ethambutol was substituted for thiacetazone. No significant association was found between recurrence among HIV-1-positive patients and initial resistance, initial treatment regimen, a diagnosis of AIDS (WHO definition), or poor compliance. DNA fingerprinting suggested that both relapse and new infection may have produced recurrence of tuberculosis. In patients who had a cutaneous hypersensitivity reaction, increased recurrence rate may have been related to interruption of treatment, subsequent poor compliance, or more advanced immunosuppression. Alternatively, a change to the combination of ethambutol and isoniazid in the continuation phase for 11 months only may not be adequate.

References (18)

P. Nunn et al.
Cutaneous hypersensitivity reactions to thiacetazone in HIV-1 seropositive patients treated for tuberculosis
Lancet
(1991)
G. Slutkin et al.
Tuberculosis and AIDS
Bull Int Union Tuberc Lung Dis
(1988)
Jp Narain, Mc Raviglione, A. Kochi, HIV-associated tuberculosis in developing countries: epidemiology and strategies...
Re Chaisson et al.
Tuberculosis in patients with the acquired immunodeficiency syndrome
Am Rev Respir Dis
(1987)
Rl Coleblunders et al.
HIV infection in patients with tuberculosis in Kinshasa, Zaire
Am Rev Respir Dis
(1989)
Pm Small et al.
Treatment of tuberculosis in patients with advanced human immunodeficiency virus infection
N Engl J Med
(1991)
E. Soriano et al.
Characteristics of tuberculosis in HIV-1 infected patients: a case-control study
AIDS
(1988)
Jh Perriens et al.
Increased mortality and tuberculosis treatment failure rate among human immunodeficiency virus (HIV) seropositive compared with HIV seronegative patients with pulmonary tuberculosis treated with "standard" chemotherapy in Kinshasa, Zaire
Am Rev Respir Dis
(1991)

There are more references available in the full text version of this article.

Cited by (120)

Recurrent tuberculosis in patients infected with the predominant Mycobacterium tuberculosis outbreak strain in Denmark. New insights gained through whole genome sequencing
2020, Infection, Genetics and Evolution
Recurrent tuberculosis (TB) is defined by more than one TB episode per patient and is caused by reinfection with a new M. tuberculosis (Mtb) strain or relapse with the previous strain. In Denmark, a major TB outbreak caused by one specific Mtb genotype “DKC2” is ongoing. Of the 892 patients infected with DKC2 between 1992 and 2014, 32 had recurrent TB with 67 TB episodes in total.
The 32 cases were evaluated in terms of number of single-nucleotide polymorphism (SNP) differences and time between episodes derived from whole-genome sequencing data.
For four TB cases, the subsequent episodes could be confirmed as relapse and for one case as reinfection. Eight cases with SNP differences <6, theoretically indicating relapse, could be classified as likely reinfections based on phylogenetic analysis in combination with geographical data. Subsequent TB episodes for the remaining 19 cases could not be classified as relapse or reinfection even though they all had a SNP difference of <6 SNPs.
In newer studies, investigating recurrent TB with the use of WGS, the number of SNPs has been used to distinguish between relapse and reinfection. The algorithm proposed for this is not valid in the Danish TB outbreak setting as our findings challenge the interpretation of few SNP differences as representing relapse. However, when including phylogenetic analysis and geographical data in the analysis, classification of 13 of the 32 cases were possible.
Modalities to monitor the treatment response in tuberculosis
2018, Indian Journal of Tuberculosis
Citation Excerpt :
The coexistence of TB and HIV affects the treatment outcome of tuberculosis. The risk of shortened survival rate and higher rate of recurrence of TB is observed more in patients with HIV-positive than HIV-negative patients.64,65 The survival rate of HIV-positive patient varies according to smear positive status and regimen.
Considering the global epidemic of drug resistance in Mycobacterium tuberculosis, early and accurate diagnosis as well as prompt initiation of antitubercular therapy (ATT) forms the mainstay of tuberculosis control programs. Patients on ATT may develop treatment failure due to diverse reasons including emergence of drug resistance in the host during the course of therapy. Monitoring the timely response to treatment in such cases has a significant role in rapid identification of drug resistant strains and institution of change of regimen to further decrease the morbidity and mortality associated with the disease. Furthermore, availability of faster surrogate end points to assess treatment efficacy, disease activity, cure, and relapse is one of the crucial requirements for undertaking innovative clinical trials related to TB. The article presents here the compilation of currently available methods for monitoring the treatment response in pulmonary as well as extrapulmonary TB.
Pulmonary infectious complications of tumor necrosis factor blockade
2010, Infectious Disease Clinics of North America
A Modern Approach to Tuberculous Pericarditis
2007, Progress in Cardiovascular Diseases
The human immunodeficiency virus (HIV) epidemic has been associated with an increase in all forms of extrapulmonary tuberculosis including tuberculous pericarditis. Tuberculosis is responsible for approximately 70% of cases of large pericardial effusion and most cases of constrictive pericarditis in developing countries, where most of the world's population live. However, in industrialized countries, tuberculosis accounts for only 4% of cases of pericardial effusion and an even smaller proportion of instances of constrictive pericarditis. Tuberculous pericarditis is a dangerous disease with a mortality of 17% to 40%; constriction occurs in a similar proportion of cases after tuberculous pericardial effusion. Early diagnosis and institution of appropriate therapy are critical to prevent mortality. A definite or proven diagnosis is based on demonstration of tubercle bacilli in pericardial fluid or on histologic section of the pericardium. A probable or presumed diagnosis is based on proof of tuberculosis elsewhere in a patient with otherwise unexplained pericarditis, a lymphocytic pericardial exudate with elevated biomarkers of tuberculous infection, and/or appropriate response to a trial of antituberculosis chemotherapy. Treatment consists of 4-drug therapy (isoniazid, rifampicin, pyrazinamide, and ethambutol) for 2 months followed by 2 drugs (isoniazid and rifampicin) for 4 months regardless of HIV status. It is uncertain whether adjunctive corticosteroids are effective in reducing mortality or pericardial constriction, and their safety in HIV-infected patients has not been established conclusively. Surgical resection of the pericardium is indicated for those with calcific constrictive pericarditis or with persistent signs of constriction after a 6 to 8 week trial of antituberculosis treatment in patients with noncalcific constrictive pericarditis.
Chemotherapy and diagnosis of tuberculosis
2006, Respiratory Medicine
Since after the first streptomycin 1944 trials, anti-tuberculous chemotherapy research has been focused upon establishing drug combination regimens capable of overcoming drug resistance and amenable to ambulatory treatment in resource strapped countries. The first milestone being the 1959 Madras trial comparing home and sanatorium treatment in South India. Subsequently, the MRC trials led Fox and Mitchison to indicate rifampicin, isoniazid and pyrazinamide as the first line drugs for short course, 6 month, regimens and the 1982 Hong Kong Chest Service trials established intermittent therapy as the ambulatory treatment standard for directly observed therapy (DOT). The rising of the HIV epidemic at the beginning of the 1980s has refuelled tuberculosis spread in Africa and Asia and contributed to the expansion of drug-resistant tuberculosis worldwide making the development of new drugs and drug regimens for ambulatory treatment a top priority.
Led by biotechnological advances, molecular biology has been brought into TB laboratory diagnosis for the highly sensitive and specific rapid identification of Mycobacterium tuberculosis in biological samples. The field of immunological diagnosis of TB infection, dominated since the early 1900s by the intradermal tuberculin reaction has been put back in motion by the discovery of M. tuberculosis-specific proteins and peptides, now employed in blood tests of high sensitivity and specificity for the diagnosis of latent TB which may help with the identification of contacts at higher risk of active disease and the eradication of pidemic cases.
The cost to health services of human immunodeficiency virus (HIV) co-infection among tuberculosis patients in Sudan
2006, Health Policy
To compare the cost of managing HIV-positive and HIV-negative tuberculosis (TB) patients in Sudan.
A prospective cohort of 1797 consecutive TB patients referred to the chest clinics within the general health services from March 1998 to March 2000 were included in this study. Patients were tested blindly for HIV; 1724 were HIV-negative and 73 were HIV-positive.
The total cost associated with management of tuberculosis was significantly higher for HIV-positive, as compared with HIV-negative TB patients (US $ 105.08 versus 73.92, p = 0.003). This difference was due mainly to greater costs for hospitalization of those HIV-positive, as compared with those HIV-negative (190.80 versus 141.00, p = 0.001). The differences in cost for diagnostic tests, for drugs, for management of adverse reactions and for intercurrent symptoms were not significant (p > 0.05) between HIV-positive TB patients and HIV-negative TB patients. Side effects of treatment were slightly more common among persons without HIV infection than among HIV-positive patients (14 and 9.6%, respectively). The total cost of management of HIV-positive patients in this series of patients was 6% of all costs for TB case management and the marginal cost attributable to HIV-positivity was 0.9% of the total cost.
The management of the HIV-positive TB case was more costly than that of the HIV-negative case in this stage of the HIV/AIDS epidemic in Sudan.

View all citing articles on Scopus

View full text

ArticlesIncreased recurrence of tuberculosis in HIV-1-infected patients in Kenya

Abstract

Lancet

Tuberculosis and AIDS

Bull Int Union Tuberc Lung Dis

Tuberculosis in patients with the acquired immunodeficiency syndrome

Am Rev Respir Dis

HIV infection in patients with tuberculosis in Kinshasa, Zaire

Am Rev Respir Dis

Treatment of tuberculosis in patients with advanced human immunodeficiency virus infection

N Engl J Med

Characteristics of tuberculosis in HIV-1 infected patients: a case-control study

AIDS

Increased mortality and tuberculosis treatment failure rate among human immunodeficiency virus (HIV) seropositive compared with HIV seronegative patients with pulmonary tuberculosis treated with "standard" chemotherapy in Kinshasa, Zaire

Am Rev Respir Dis

Articles
Increased recurrence of tuberculosis in HIV-1-infected patients in Kenya