Prevention and treatment of tuberculosis in HIV infection. Treatment of tuberculosis in AIDS Patients with HIV or tuberculosis

Tuberculosis in HIV-infected patients proceeds malignantly, has a tendency to progress and progress due to severe immunodeficiency.

Identification of a patient with and progressive tuberculosis

culosis serves as a signal to the need for a targeted examination of it for HIV infection. At the same time, AIDS patients should be considered as potential TB patients. Epidemic

HIV infection has brought and continues to make radical changes in the epidemiology of tuberculosis. The main impact of HIV infection is expressed in the rate of progression of clinically significant tuberculosis in persons previously infected with MVT.

It is known that tuberculosis and HIV infection can be combined in three ways:

1 - primary infection with tuberculosis of HIV-infected patients

Simultaneous infection with HIV infection and tuberculosis;

The development of the tuberculous process against the background of the development of immunode-

physitis in HIV infection (AIDS).

Epidemiology. Individuals infected with both TB and HIV are at particularly high risk of the disease. They have an annual probability of developing tuberculosis is 10%, while for the rest of the population, this probability does not exceed 5% throughout life. In countries with a high HIV infection rate, more than 40% of TB patients are also infected. Due to the growing AIDS epidemic, epidemiological forecasts are very unfavorable.

An epidemiological analysis of the data shows that the main route of transmission of HIV infection in Russia is parenteral, which occurs in the vast majority of cases through the administration of drugs (96.8% of cases of established routes of transmission). Among the other high-risk groups of the disease (patients with sexually transmitted infections, people with a homosexual orientation), the percentage of confirmed cases of HIV infection is much lower, but in recent years there has been an increase in the incidence of sexual transmission.

The source of HIV infection is an HIV-infected person at all stages of the disease. The most likely transmission of HIV is from a person who is at the end of the incubation period, at the time of the initial manifestations and in the late stage of infection, when the concentration of the virus reaches a maximum, but the virus in the blood is little neutralized by antibodies. Susceptibility to HIV in humans is universal.

Almost all biological fluids of an HIV-infected person (blood, semen, vaginal and cervical secretions, urine, CSF and pleural fluid, breast milk) contain viral particles in varying concentrations. However, the most

Chapter

The greatest danger of HIV transmission is blood and semen.

Pathogenesis And pathomorphology. The factors explaining the regularity of the predominant combination of tuberculosis and HIV infection are the peculiarities of the mechanisms of pathogenesis of both diseases.

HIV infection significantly affects the state of immunoreactivity in tuberculosis, changing the relationship in the system of cellular immunity, disrupting the differentiation of macrophages and the formation of specific granulation tissue. Accordingly, a more frequent development of tuberculosis in HIV-infected people can occur both due to a decrease in resistance to primary or re-infection (exogenous infection), and as a result of reactivation of old residual post-tuberculosis changes in the weakening of anti-tuberculosis immunity (endogenous reactivation).

Histomorphological manifestations of tuberculous inflammation in HIV infection also show a clear correlation with the number of CD4+ cells in the blood. As their level falls, the following changes are observed in the zone of tuberculous inflammation: the number decreases, and then the typical tuberculous granulomas completely disappear, they lack the characteristic Pirogov-Langhans cells. This significantly reduces the number of epithelioid cells; the number of macrophages may increase, but the inferiority of their function is expressed in the inability to form granulomas.

The tissue reaction is manifested mainly by cheesy necrosis with a large number of exudative-proliferative processes that are very weakly expressed. This is largely due to an increase in expression In the development of tuberculosis

in an HIV-infected patient, as a result of an increased release of this lymphokine, a necrotic process develops in the lungs.

The presence of typical necrosis is characteristic of the terminal period of AIDS in tuberculosis. Affected tissues quickly undergo massive liquefaction and are literally “stuffed” with MBT. In the late stages of HIV infection, active tuberculous process is the main cause of death in almost 90% of cases. In this case, as a rule, hematogenous generalization of tuberculosis with pulmonary and extrapulmonary metastases takes place, therefore, some authors tend to consider the detection of combined pulmonary and extrapulmonary localizations of tuberculosis as one of the signs of AIDS.

There are frequent cases of combined development of tuberculosis and other AIDS-indicating diseases (pneumocystis pneumonia, toxoplasmosis, cytomegalovirus infection, sarcoma

clinical picture. The severity of the clinical manifestations of the tuberculous process is the greater, the smaller the number of CD4+ cells circulating in the peripheral blood. With an unfavorable prognosis for life in individuals with comorbidities, the immunogram shows a sharp decrease in the number of CD4+ lymphocytes, B-lymphocytes and natural killers, an increase in the concentration of IgG, M, A, a sharp increase in circulating immune complexes and a decrease in the functional activity of neutrophils. In such cases, the progression of tuberculosis against the background of chemotherapy in 30% of cases leads to death.

The main clinical manifestations of tuberculosis against the background HIV infections are asthenia, persistent or intermittent fever, prolonged cough, significant weight loss, diarrhea, swollen lymph nodes (mainly cervical and axillary, less often inguinal), dense, lumpy, poorly displaced on palpation. The severity of tuberculosis symptoms in HIV-infected and AIDS patients largely depends on the degree of inhibition of cellular immunity.

The disease often proceeds as an infiltrative or generalized process. The most typical complaints are weakness, cough, high fever and sweating. Characterized by a significant weight loss of the patient, weight loss is 10-20 kg and is always more than 10% of the original. More pronounced clinical symptoms are observed in patients who developed tuberculosis on the background of HIV infection than in patients with tuberculosis who later became infected with HIV and developed AIDS.

Manifestations of tuberculosis, when the number of lymphocytes is still quite high, may be the most typical and do not differ in any way from the clinical and radiological picture in HIV-negative patients.

At this stage, the usual manifestations of predominantly pulmonary tuberculosis dominate in patients. Upper lobe infiltrative and less often focal processes develop, in half of the cases with decay, therefore, specific therapy is effective, and tuberculosis is cured. As the number of CD4+ lymphocytes in the blood decreases

(up to 200 in 1 mm 3 or less), along with pulmonary lesions (or instead of them), extrapulmonary localizations of tuberculosis are increasingly being detected.

The features of the clinical symptoms of tuberculosis in these cases are an increased frequency of extrapulmonary and disseminated lesions; negative skin reactions to tuberculin as a manifestation of anergy, atypical changes on chest radiographs, and the relative rarity of cavitation.

Clinical manifestations of tuberculosis are often atypical. When the lungs are affected, lobar infiltrates radiologically do not have a typical localization, often the process is prone to dissemination (miliary tuberculosis).

Especially often, the lymph nodes and meningeal membranes, as well as the pleura, are involved in the pathological process. In many patients, tuberculin sensitivity is reduced, with the frequency of negative reactions inversely proportional to the level of CD4+ lymphocytes.

Recently, there are more and more reports of the predominance of extrapulmonary localization of tuberculosis in HIV-infected individuals. At the same time, it is possible to develop a specific process in the cervical, mesenteric, less often tonsillar lymph nodes, as well as in the muscles of the chest and abdominal cavity and in the brain with the development of specific abscesses and leaks. Often this leads to the death of the patient, despite the specific and surgical treatment.

When a deep damage to the immune system is detected when

Tuberculous changes in the lungs in AIDS patients are characterized by a more frequent development of hilar adenopathy, miliary rashes, the presence of predominantly interstitial changes and the formation of pleural effusion. At the same time, their upper parts of the lungs are significantly less frequently affected, and the caverns and atelectasis characteristic of tuberculosis are not so often formed. Quite often, in patients with AIDS, instead of miliary rashes on radiographs of the lungs, diffuse merging infiltrative changes are found, proceeding according to the type of caseous pneumonia. A significantly more frequent development of tuberculous mycobacteremia is considered very characteristic, which in patients WITH P ANDD om is complicated by septic shock with dysfunction of many organs.

Diagnostics tuberculosis in HIV-infected persons is carried out on the basis of standard methods of mandatory clinical examination, consisting of:

study of complaints and anamnesis of the patient;

objective examination;

blood and urine tests;

chest x-ray;

triple microscopic examination of sputum and her sowing on nutrient media;

evaluation of intradermal Mantoux reaction with 2 TU PPD-L;

ELISA tuberculosis antibodies and tuberculosis antigens. Difficulties in diagnosing tuberculosis arise mainly in the stage

secondary manifestations, including AIDS. The predominance of disseminated and extrapulmonary forms during this period with a sharp decrease in the number of cases of lung tissue decay significantly reduces the number of patients in whom sputum is detected by microscopy (according to the Ziehl-Nelsen method) and culture. However, it must be taken into account that during this

the period of the course of HIV infection and AIDS in almost all patients is determined by mycobacteremia and the detection of the pathogen in the peripheral blood is the most important diagnostic test.

Given the high frequency of extrapulmonary lesions in patients with tuberculosis and AIDS, an important role in the diagnosis is played by biopsies of the lymph nodes, spleen, liver, bone marrow and other organs, where acid-fast mycobacteria can be detected in biopsy specimens in more than 70% of patients. In the pathoanatomical examination of biopsy specimens, signs of a decrease in the reactivity of the organism are often determined, which manifests itself in an extremely weak formation of granulomas with a predominance of necrosis, and in more than half of the cases, granulomas characteristic of tuberculosis are absent.

The study of tuberculin sensitivity according to the Mantoux test with 2 TU PPD-L and ELISA for the determination of anti-tuberculosis antibodies and MBT antigens have limited diagnostic significance due to immunosuppression and anergy to patients with tuberculosis and AIDS.

Frequent extrapulmonary localization in patients with tuberculosis and AIDS suggests widespread use in the diagnosis of unclear cases CT.

Treatment. Chemotherapy for respiratory tuberculosis in HIV-infected patients is highly effective. A common aspect of the treatment of patients with tuberculosis and AIDS is the simultaneous administration of several antiretroviral drugs (nucleoside and non-nucleoside reverse transcriptase inhibitors and viral protease inhibitors).

Currently, the appointment of antiretroviral drugs is becoming a necessary element in the treatment of tuberculosis with advanced forms of infection. At the same time, WHO recommends distinguishing three options for clinical situations where anti-tuberculosis chemotherapy should be combined with aniretroviral treatment:

tuberculosis patients with a CD4+ lymphocyte count of more than 350/mm3 usually do not need antiretroviral therapy and receive only chemotherapy;

tuberculosis patients with CD4+ lymphocyte count from 350 to 200 per mm 3 antiretroviral therapy is prescribed at the end of the intensive phase of chemotherapy after 2-3 months from the start of treatment;

tuberculosis patients with a CD4+ lymphocyte count of less than 200/mm3 are prescribed antiretroviral therapy concomitantly with chemotherapy.

Chemotherapy for tuberculosis in HIV-infected and AIDS patients, in principle, is no different from the treatment regimens for HIV-negative patients and is carried out according to general rules.

HIV-infected patients with newly diagnosed pulmonary tuberculosis in the intensive phase of chemotherapy for 2-3 months receive four main anti-tuberculosis drugs: isoniazid, rifampicin, pyrazinamide and ethambutol.

It should be noted that antiretroviral drugs such as protease inhibitors are inactivated by an enzyme whose activity is increased by rifampicin. In this regard, it is more expedient to use rifabutin, a synthetic analogue of rifampicin, in chemotherapy regimens. A number of antiretroviral drugs (Zerit, Videx, Quivid) in combination with isoniazid mutually enhance neurotoxicity, therefore, in chemotherapy regimens, it is better to use phenazid, a drug from the group that does not have neurotoxicity.

When drug resistance is detected, correction is carried out

chemotherapy and prolong the duration of the intensive phase of treatment. It is possible to combine the main ones, to which the sensitivity of the MBT has been preserved, and reserve drugs, however, the combination should consist of five drugs, of which at least two should be reserve.

The indication for the continuation phase of treatment is the cessation of bacterial excretion by sputum microscopy and a positive wedge.

co-radiological dynamics of the process in the lungs. The continuation phase of treatment lasts 4-6 months with isoniazid and rifampicin or isoniazid and ethambutol.

The total duration of treatment is determined by the timing of the cessation of bacterial excretion and stabilization of the process in the lungs. Due to the risk of low efficiency of the combination of reserve drugs, as well as recurrence of tuberculosis caused by multi-resistant strains of MBT, chemotherapy is carried out for at least 18-22 months. At the same time, it is very important to provide long-term treatment of such patients with reserve anti-tuberculosis drugs.

TESTQUESTIONSTOPARTSII

PRIVATEQUESTIONSPhthisiopulmonology

1. The domestic clinical classification of tuberculosis was created on the basis of:

a) the pathogenesis of the disease;

b) morphological manifestations of the disease;

c) clinical manifestations of the disease;

d) X-ray picture of the disease;

e) all of the above.

2. The main method for diagnosing tuberculosis of the respiratory organs in children:

a) X-ray tomography;

b) bacterioscopic;

c) bacteriological;

d) tuberculin diagnostics;

e) biological.

3. A form of tuberculosis, which is characterized by the development of inflammatory changes in the lung tissue and regional intrathoracic lymph nodes:

a) focal pulmonary tuberculosis;

b) primary tuberculosis complex;

c) infiltrative pulmonary tuberculosis;

d) fibrous-cavernous pulmonary tuberculosis;

e) tuberculosis of the intrathoracic lymph nodes.

4. A group of intrathoracic lymph nodes located in the region of the lung root:

a) paratracheal;

b) tracheobronchial;

c) bifurcation;

d) bronchopulmonary.

5. Dullness of percussion sound with the quietest percussion along the spinous processes of the thoracic vertebrae from the bottom up is called a symptom:

b) d "Espina;

c) Widerhoffer;

d) Frank;

e) Filatov.

6. The form of tuberculosis most frequently found in the structure of the disease in children:

a) primary tuberculosis complex;

b) tuberculosis of intrathoracic lymph nodes;

c) tuberculous pleurisy;

d) tuberculosis intoxication;

e) disseminated tuberculosis.

7. A form of pulmonary tuberculosis, which is characterized by the presence of bilateral focal changes in the lung tissue:

a) focal tuberculosis;

b) disseminated tuberculosis;

c) infiltrative tuberculosis;

d) fibrous-cavernous tuberculosis;

e) tuberculous pleurisy.

8. Small-focal disseminated generalized process is called:

a) alveolar;

b) broncholobular;

c) miliary;

d) acinar;

e) caseous.

9. The most typical genesis of the development of miliary pulmonary tuberculosis:

a) lymphogenous;

b) hematogenous;

c) bronchogenic;

d) contact;

e) aerogenic.

10. The development of disseminated pulmonary tuberculosis is most often combined with lesions:

a) larynx;

b) liver;

c) heart muscle;

d) spleen; e)

According to the clinical course of miliary tuberculosis, the following forms are distinguished:

a) subacute and chronic;

b) cavernous, tumorous and cirrhotic;

c) diffuse and local;

d) pulmonary, typhoid and meningeal;

e) focal and infiltrative.

12. The highest lethality in disseminated pulmonary tuberculosis is observed in:

a) typhoid variant of the course;

b) meningeal variant of the course;

c) pulmonary variant of the course;

d) subacute course;

e) chronic course.

13. Differential diagnosis of miliary tuberculosis is carried out with:

a) chronic tuberculosis intoxication;

b) chronic bronchitis;

c) Werlhof's disease;

d) typhoid fever;

e) aspergillosis.

14. A doctor of the general medical network may suspect the presence of pulmonary tuberculosis in a patient on the basis of:

a) patient complaints;

b) data of an objective examination of the patient;

c) general blood test;

d) urinalysis data;

e) data of bacterioscopic examination of sputum.

15. X-ray picture of soft-focal pulmonary tuberculosis is characterized by:

a) the presence of foci of increased intensity with clear contours against the background of pneumosclerotic changes in the apex of the lung;

e) the presence of a focal shadow of medium intensity 2.5 cm in diameter at the level of the 4th rib.

16. X-ray picture of fibro-focal pulmonary tuberculosis is characterized by:

a) the presence of foci of increased intensity with clear contours against the background of pneumosclerotic changes in the area of ​​the apex of the lung;

b) the presence of foci of low intensity with fuzzy, blurry contours and a tendency to merge in the region of the apex of the lung;

c) the presence of focal shadows of an inhomogeneous structure extending from the apex to the 3rd rib;

d) the presence of foci of low and medium intensity in all lung fields;

e) the presence of a focal shadow of medium intensity 2.5 cm in diameter.

17. The most common outcome of mild-focal form of pulmonary tuberculosis with favorable regression:

a) transition to the cavernous form of pulmonary tuberculosis;

b) transition to pulmonary tuberculosis;

c) transformation into cirrhotic pulmonary tuberculosis;

d) transformation into fibro-focal pulmonary tuberculosis;

e) transition to disseminated pulmonary tuberculosis.

18. The most likely outcome of focal pulmonary tuberculosis in its progressive course is the transition to:

a) fibrous-cavernous pulmonary tuberculosis;

b) cirrhotic pulmonary tuberculosis;

c) tuberculoma;

d) cavernous form of pulmonary tuberculosis;

e) infiltrative pulmonary tuberculosis.

19. X-ray picture of a cloudy infiltrate is characterized by the presence of:

d) darkening of the middle or. increased intensity, occupying the entire lobe of the lung, while the lower contour is clear, along the interlobar fissure;

e) a large number of caseous foci of a confluent nature, against which multiple cavities and decays are determined.

20. X-ray picture of pulmonary tuberculosis of the lobitis type is characterized by the presence of:

b) heterogeneous darkening, medium or low intensity without clear boundaries, limited or widespread with a tendency to destructive changes;

c) a shadow of medium intensity, located at the base, on an underlined interlobar pleura and having a vague upper-medial contour, in the form of a triangle;

d) darkening of medium or increased intensity, occupying the entire lobe of the lung, while the lower contour is clear, along the interlobar fissure;

e) a large number of high-intensity confluent foci, against which multiple caverns are identified.

21. X-ray picture of a round infiltrate is characterized by the presence of:

a) rounded shadows with clear boundaries, low or medium intensity, fairly uniform;

b) heterogeneous darkening, medium or low intensity without clear boundaries, limited or widespread with a tendency to destructive changes;

c) a shadow of medium intensity, located at the base on the underlined interlobar pleura and having a blurry contour, in the form of a triangle;

d) darkening of medium or increased intensity, occupying the entire lung, while the lower contour is clear along the interlobar fissure;

22. X-ray picture of infiltrative tuberculosis of the periscissuritis type is characterized by the presence of:

b) rounded shadows with clear borders, low or medium intensity, fairly uniform;

c) a shadow of medium intensity, located at the base on the underlined interlobar pleura and having a blurry upper-medial contour, in the form of a triangle;

23. X-ray picture of broncholobular infiltrative tuberculosis is characterized by the presence of:

a) a shadow of medium intensity, located subpleurally at the base and converging towards the root of the lung, occupying one segment;

b) rounded shadows with clear borders, low or medium intensity, fairly uniform;

c) a shadow of medium intensity, located at the base on an underlined interlobar pleura and having a blurry upper medial contour;

d) darkening of medium or increased intensity, occupying the entire lobe of the lung, while the lower contour is clear along the interlobar fissure;

e) a large number of high-intensity confluent foci, against which multiple caverns are identified.

24. Infiltrate from a pathomorphological point of view is:

a) site of destruction of the lung;

b) focus of caseosis with a zone of Pirogov-Langhans epithelioid cells and perifocal inflammation around;

c) irreversible fibrotization of the lung parenchyma;

d) accumulation of fluid in the interlobar pleural cavity;

e) multiple focal caseous necrosis of the lung.

25. X-ray picture of caseous pneumonia is characterized by the presence of:

a) rounded shadows with clear boundaries, low or medium intensity, fairly uniform;

b) heterogeneous darkening, medium or low intensity without clear boundaries, limited or widespread with a tendency to destructive changes;

c) a shadow of medium intensity, located at the base on the underlined interlobar pleura and having a vague upper medial contour, in the form of a triangle;

d) darkening, occupying the entire lobe of the lung;

e) a large number of high-intensity foci of a confluent character, against which multiple decay cavities are determined.

26. Negative reaction to tuberculin in patients with caseous pneumonia is:

a) a sign of good drug tolerance;

b) a good prognostic sign;

c) poor prognostic sign;

d) the basis for changing the diagnosis;

e) evidence of the absence of BCG in childhood.

27. A disease with severe intoxication and high temperature with a negative Mantoux test with 2 TU PPD-L is typical for:

a) primary tuberculosis complex;

b) caseous pneumonia;

c) acute disseminated tuberculosis;

d) fibrinous pleurisy;

e) fibrous-cavernous tuberculosis.

28. Caseous pneumonia must be differentiated from:

a) croupous pneumonia;

b) infiltrative pulmonary tuberculosis;

c) exudative pleurisy;

d) primary tuberculosis complex;

e) tuberculous bronchoadenitis.

29. The formation of tuberculoma is most often observed in persons with:

a) high probability of HIV infection;

b) high natural resistance of the organism;

c) low resistance and lack of immunity;

d) inadequate administration of glucocorticoids;

e) long-term use of cytostatics.

30. The main methods for detecting tuberculomas include:

a) collection of anamnesis data;

b) data of clinical objective examination of the patient;

c) data of laboratory research methods;

d) results of fluorographic examination;

e) results of tracheobronchoscopic examination.

31. To avoid surgical intervention in the treatment of tuberculoma, the appointment of:

a) glucocorticoids;

b) gamma globulins;

c) interferon;

d) lidase, tuberculin, pyrogenal;

e) thymolin, decaris.

32. Greatest stability and asymptomatic course is different:

a) infiltrative pulmonary tuberculosis;

b) fibrous-cavernous pulmonary tuberculosis;

c) disseminated pulmonary tuberculosis;

d) tuberculoma;

e) exudative pleurisy.

33. One of the methods of treatment of tuberculosis is:

a) the imposition of an artificial pneumothorax;

b) drainage of the pleural cavity;

c) method of limiting concentrations of drugs;

d) imposition of artificial pneumoperitoneum;

e) lung resection.

34. A form of pulmonary tuberculosis, which is characterized by the presence of an isolated cavity formation:

a) disseminated pulmonary tuberculosis in the decay phase;

b) infiltrative pulmonary tuberculosis in the decay phase;

c) cavernous pulmonary tuberculosis;

d) focal pulmonary tuberculosis in the decay phase;

e) fibrous-cavernous pulmonary tuberculosis.

35. Cavernous tuberculosis looks like:

a) focal shadow

b) groups of foci;

c) total blackout;

d) linear shadow;

e) an annular shadow.

36. Cavernous pulmonary tuberculosis is characterized by radiological signs in the form of a closed annular shadow against the background of:

a) unaltered lung tissue with lymphangitis efferent path towards the root of the lung;

b) pronounced inflammatory changes in the lung tissue;

c) a large number of confluent foci;

d) pronounced fibrotic changes in lung tissue;

e) massive pleural adhesions.

37. The rapid increase in the volume of the cavity leads to:

a) progression of tuberculosis;

b) violation of the drainage function of the bronchus;

c) violation of blood circulation in the surrounding tissue of the lung;

d) formation of bronchopleural fistula;

e) thinning of the cavity wall.

38. Cavernous tuberculosis can form from:

a) primary tuberculosis complex with decay;

b) progressive tuberculoma;

c) infiltrative pulmonary tuberculosis with decay;

d) disseminated pulmonary tuberculosis with decay;

e) all of the listed forms.

39. To increase the effectiveness of treatment of patients with cavernous pulmonary tuberculosis, you can:

a) the appointment of a course of hormonal therapy;

b) the use of ultrasound therapy;

c) the appointment of lidase or pyrogenal;

d) the imposition of pneumothorax or pneumoperitoneum;

e) prescription of broad-spectrum antibiotics.

40. Fibrous-cavernous pulmonary tuberculosis is characterized by radiological signs in the form of:

a) the presence of a cavity with walls of increased intensity;

b) foci of bronchogenic dissemination;

c) decrease in lung volume on the side of the pathological process with displacement of the mediastinal organs towards the lesion;

d) deformation of the bone skeleton in the form of beveled ribs and reduced intercostal spaces on the side of the lesion, expansion of the intercostal spaces in the underlying sections;

e) all of the above.

41. The clinical course of fibrous-cavernous pulmonary tuberculosis is most often characterized by:

a) undulating progressive course;

b) frequent spontaneous remissions;

c) long-term stable condition of the patient;

d) steady improvement in the patient's condition;

e) long asymptomatic course.

42. Fibrous-cavernous pulmonary tuberculosis most often has to be differentiated from:

a) croupous pneumonia;

b) decaying lung cancer;

c) tuberculosis of the intrathoracic lymph nodes;

d) sarcoidosis;

e) chronic bronchitis.

43. Among died of pulmonary tuberculosis the most common forms are:

a) focal;

b) disseminated;

c) fibrous-cavernous;

d) cavernous;

e) infiltrative.

Doctors are faced with the difficulty of detecting tuberculosis (consumption, Koch's bacillus) in HIV-positive patients: due to weakened immunity and changes in the pathogenesis of the disease, standard diagnostic methods (fluorography and tuberculin tests) become uninformative. The course of the disease is characterized by severity, malignancy, a tendency to complications and generalization of the process - first affecting, for example, the lungs. Gradually, tuberculosis spreads to other organs and systems.

The combination of two diagnoses - tuberculosis and HIV - is a fairly common phenomenon. In modern medical literature, they are even called satellite infections, which is due to a number of factors:

• a similar contingent for each disease: drug addicts, prisoners, persons with low social responsibility;
• high infection of the population with Koch's bacillus, which can exist latently in the human body for years and never provoke a disease under the condition of strong immunity; since with HIV immunity is reduced and cannot fight infections, mycobacteria begin to multiply actively, which leads to the development of tuberculosis;
• dependence of HIV and tuberculosis on the same cells - HIV primarily affects T-lymphocytes, which are also primarily responsible for the cellular response when infected with mycobacteria.

The statistics on the combination of two diseases is not comforting:

• the probability of contracting tuberculosis in an HIV patient is several tens of times higher than in a healthy person;
• consumption ranks first in HIV mortality from secondary infections;
• up to half of AIDS patients have an open form of tuberculosis.

How long a person will live if he is diagnosed with consumption and HIV depends directly on his lifestyle. If you follow the prescriptions of doctors, take all the necessary medicines, give up bad habits (primarily for drug addicts), then it is possible to achieve stabilization and live with two diagnoses for 15-20 years. But if treatment is ignored and proper behavior is abandoned, life expectancy is reduced to 1 year.

HIV infection and tuberculosis together

Generalization of tuberculosis foci in HIV depends on the stage of immunodeficiency and the level of CD4-lymphocytes:

• high level (more than 500 cells per 1 µl) - a typical clinical picture of tuberculosis with a predominant lesion of the chest organs;
• average level (350-500 cells per 1 µl) - in addition to severe pulmonary forms with pleurisy - lymphogenous generalization of tuberculosis with damage to the intrathoracic, peripheral, abdominal and retroperitoneal lymph nodes;
• low level (less than 350 cells per 1 µl) - atypical forms of tuberculosis, hematogenous generalization of the process with damage to bones, joints, gastrointestinal organs, skin, brain, heart; the most severe stage is tuberculous sepsis.

HIV-associated tuberculosis can occur in two forms:

• latent (or hidden) - the clinical picture is not pronounced, but in the body there is a process of spreading mycobacteria and damage to the lymphatic tissue and other organs;
• active - pronounced manifestations of the disease, depending on the generalization of the process.

Tuberculosis in HIV further exacerbates immunodeficiency, which contributes to the addition of opportunistic infections caused by opportunistic viruses or bacteria that are not dangerous for a healthy person: pneumocystis pneumonia, fungal infections of the abdominal organs, bacterial or fungal meningitis. The combination of such diagnoses is practically untreatable and most often leads to death.

Types of combinations of tuberculosis and HIV

There are three options for the development of consumption in HIV infection:

• the patient fell ill with tuberculosis, already having an HIV-positive status;
• the patient initially suffered from consumption and then became infected with HIV;
• the patient was simultaneously infected with HIV and Koch's bacillus.

The third option is the most severe in terms of the clinic and the outcome of the disease, most often observed in people with alcohol or drug addiction.

Symptoms indicating two ailments

Tuberculosis in HIV is the more difficult, the more pronounced immunodeficiency. But there are signs that appear regardless of the form, stage and concomitant diseases:

• intoxication of the body - fever, night sweats, weakness, fatigue, weight loss of more than 15%, exhaustion. This condition can last from several weeks to six months;
• bronchopulmonary manifestations (with generalization of the process in the organs of the chest) - cough (dry or with sputum), shortness of breath, hemoptysis;
• enlarged lymph nodes (cervical, supraclavicular, inguinal); on palpation, the nodes are dense, painful, without displacement. With the progression of the disease, the formation of fistulas and ulcers over the lymph nodes and adjacent tissues is possible;
• decrease in hemoglobin level less than 100 g/l;
• digestive disorders: nausea, vomiting, constipation or diarrhea, loss of appetite;
• pain in the bones and joints.

Such a clinical picture can also occur with other diseases, but if the patient is HIV-positive, then the presence of at least one of the listed signs may indicate consumption. In this case, it is necessary to carry out a set of diagnostic measures to confirm the diagnosis:

• standard procedures:

1. phthisiatrician examination,
2. general clinical blood and urine tests,
3. x-ray of the chest in two projections,
4. bacteriological examination of sputum,
5. assessment of skin reaction to tuberculin test;

• special procedures:

1. enzyme immunoassay, PCR or plasma analysis for the presence of mycobacteria,
2. bronchoscopy with biopsy if necessary,
3. Ultrasound of the abdominal organs,
4. MRI of internal organs, joints, spine or brain,
5. MSCT of the chest,
6. biopsy of lymph nodes, bone marrow, spleen.

The danger of combining tuberculosis and HIV

The danger lies in the complexity of diagnosis, the atypical clinical picture, the fulminant course and the severity of complications. If in an initially healthy person the transition from one stage and form of tuberculosis to another can take several years, then in an HIV-infected patient, the manifestation of consumption can occur immediately in the last incurable stages.

The most critical for the patient is the combination of two diagnoses - tuberculosis and AIDS. Usually, when infected with a Koch wand at the AIDS stage, it is not the lungs that are affected, but the lymph nodes, bones, heart and other organs. It is almost impossible to cure such a complex of diseases, it becomes difficult even to maintain physical activity and normal life of the patient. Life expectancy in this case is reduced to several months.

Tuberculosis and HIV in children

When combined, TB and HIV are 6 times more likely to kill children than adults. As a rule, children acquire HIV in utero or during childbirth from an HIV-infected mother. If the mother led an antisocial lifestyle or was a drug addict, then there is a high probability of having a premature baby with a concomitant infection (in addition to HIV) - viral hepatitis, toxoplasmosis, fungal diseases, syphilis. The immature immune system of a newborn cannot cope with such a set of diagnoses, and if tuberculosis joins this list, then the child has practically no chance of survival.

Usually, healthy newborns are vaccinated on the 3rd-5th day of life with BCG, an anti-consumption vaccine prepared from weakened mycobacteria. But if a child is born from an HIV-infected mother, then such a vaccination cannot be done: an immunodeficiency state will provoke the development of tuberculosis even from weakened pathogens.

Features of the prescribed treatment

Usually, the same regimens are used for the treatment of tuberculosis in HIV-infected patients as for HIV-negative patients. The difference is that in patients with combined diagnoses, side effects of drugs are more often and more pronounced. Concomitant pathologies (especially candidiasis of the gastrointestinal tract and hepatitis) impede treatment in full: due to impaired liver and kidney function, drugs are poorly “absorbed” by the body. The simultaneous use of many toxic drugs is poorly tolerated by patients, therefore, consumption is primarily treated (as a more rapidly developing disease than HIV). After stabilization of the patient's condition or achievement of remission for tuberculosis, anti-HIV therapy is continued.

A high mortality rate in tuberculosis and HIV is usually associated not with the ineffectiveness of anti-tuberculosis or antiretroviral therapy, but with the severe course of all concomitant diagnoses in HIV.

Prevention of tuberculosis among HIV-infected patients is of great importance. There are several key areas:

• The best and most effective method of prevention is the timely and competent treatment of HIV: while maintaining CD4-lymphocytes at a high level, the risk of contracting tuberculosis is reduced, since the immune system is still able to resist the disease.
• Exclusion of contact with patients with tuberculosis, which implies a change in lifestyle - the rejection of drugs, a change in social circle, compliance with doctor's prescriptions and regimen.
• Preventive examinations and examinations.
• If HIV-infected patients have an inactive stage of the disease (latent infection with Koch's bacillus), then tuberculosis chemoprophylaxis is mandatory.

Compliance with simple measures and timely access to a doctor can save the patient from the severe consequences of HIV-associated tuberculosis and significantly increase the duration and quality of life.

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 comorbidity.

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, it is they that provide protection against mycobacteria, and this explains why tuberculosis develops so easily with HIV.

When T cell levels decrease, the chance 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, mycobacteria are among the leading causes of death in immunocompromised patients.

If we consider the structure of mortality from secondary diseases associated with HIV, it is tuberculosis that takes the first place of little honor.

The mechanism of the pathological process

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

T-cells with HIV infection 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 to the lung area. Namely, they are a favorite place for the localization of mycobacteria.

Alertness

Given the frequent combination of tuberculosis and HIV infection, this combination must be alert in the practice of a general practitioner, 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 people with immune defects, it is necessary to carefully conduct an examination so as not to miss tuberculosis, since in this case the prognosis for the patient's health and life deteriorates significantly.

It is important to know that mycobacteria can infect the body of an HIV-infected patient, no matter 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. So, 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) proceeds with a typical clinical picture.

At the same time, the following features are characteristic of it:

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

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

Level of CD4+lymphocytes 350-500

As immunodeficiency progresses, CD4+ lymphocyte levels decrease. With their content 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.

Level of CD4+lymphocytes<350

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

This form of the disease is characterized by:

• Severe fever (up to 39 ° and above).
• Progressive weight loss.
• Night sweats.
• Strong weakness.
• The cough may be mild, almost always dry, without sputum production.
• Uncharacteristic hemoptysis.

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

Stage AIDS

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

AIDS is the terminal stage of the disease, in which any antiretroviral treatment does not show much effect. It occurs when the level of CD4+ lymphocytes falls below 200 cells per microliter.

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

But most often it is possible for patients to live only 1-2 years. If tuberculosis joins, the prognosis is much worse.

Diagnostics

• Subfebrile condition or fever.
• Cough - dry or wet.
• Weight loss.
• Night sweats.

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

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

The earlier the diagnosis is established in this category of patients, the higher their chances of survival.

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

Features of diagnostics

HIV infection and acquired immunodeficiency syndrome affect the course of the disease. Therefore, in the diagnosis of pulmonary lesions, these features must be taken into account. Among them, the most important are:

• Any changes in the lungs at the AIDS stage should be considered as a possible tuberculosis due to the atypical course of the disease.
• In the absence of confirmation, antibacterial anti-tuberculosis drugs (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 non-specific drugs.
• If infection with mycobacteria is suspected, sputum must be examined microscopically according to Ziehl-Nielsen, in addition, it is sown on special nutrient media.
• Rapid diagnostic options (PCR or BACTEC) are used.

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

• Radiography.
• CT scan.
• Bronchoscopy.
• Lung biopsy - transthoracic or transbronchial.
• Biopsy of the pleura.

Diagnosis by CD4+ lymphocyte count< 350

Usually, the first examination for a patient with HIV and suspected pulmonary tuberculosis is an x-ray. In a situation where the number of CD4 + lymphocytes is significantly reduced, the radiographic picture also changes.

Patients will have:

• The defeat of all parts of the lungs equally.
• Preferential involvement in the process of intrathoracic lymph nodes.
• Specific pleurisy and pericarditis.
• Disseminated forms of the disease.
• More rare detection of destructive forms of the infectious process.
• Rapid progression of the disease on radiographs.

Inconsistency of clinical manifestations with 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 a deep immunodeficiency, due to the lack of body resistance, there may be no changes at all on an x-ray.

Tuberculosis and HIV in children

Many children are now infected with HIV and the number is increasing 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 should be ruled out in all young patients with HIV. However, the converse is also true.

Tuberculosis screening in HIV-infected children is carried out as in healthy children. When collecting an anamnesis, contacts with patients with tuberculosis are checked, a thorough clinical examination is carried out. An annual Mantoux test (or alternative diagnostic method) and a chest x-ray are mandatory. Early detection of tuberculosis in children improves the effectiveness of treatment and increases 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 due, rather, to an insufficient level of diagnosis than a low incidence.

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

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

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

The course of the extrapulmonary form

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

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

Local changes are determined by the organ that is affected by mycobacteria. So, for example, with abdominal tuberculosis with lesions of the mesenteric lymph nodes, peritoneum, intestines, the first complaint of patients will be pain in the abdomen.

It can be chronic, dull or sharp, cramping. Often, tuberculous mesadenitis simulates a clinic of an acute abdomen. Also, patients will note a violation of appetite, up to its absence, 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. Contrasting is used to detail formations in these zones.
• Magnetic resonance imaging. Most often, it is prescribed for suspected tuberculosis of the central nervous system.
• Ultrasound examination of the lymph nodes.

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

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

Prevention

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

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

It also includes the 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 tubinfection. And doctors prescribe chemoprophylaxis to prevent the spread of the process. It is mandatory in immunocompromised patients.

Treatment

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

If possible, antiretroviral therapy is postponed for some time. However, it significantly reduces mortality among patients with co-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. With good results, 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 care often suffers.

HIV infection and tuberculosis are an extremely dangerous combination. However, with proper treatment, patients can maintain the usual duration and decent quality of life.

The combination of HIV/AIDS and tuberculosis infection is defined as "Co-infection" - this is active pulmonary or extrapulmonary tuberculosis that develops in people with immunodeficiency.

It is diagnosed in such cases:

• tuberculosis of a patient with HIV infection;
• detection of HIV infection in a patient with tuberculosis;
• detection of both diseases simultaneously in a patient during a preventive or diagnostic examination.

Every doctor knows: HIV and tuberculosis are the most severe comorbid pathologies that require timely detection and comprehensive treatment. One disease worsens the course and prognosis of another.

The spread of HIV infection entails an increase in the incidence of tuberculosis. Tuberculosis infection, in turn, is the main cause of death in AIDS patients. The photos and videos in this article will help you understand how relevant this problem is and how to deal with it.

The immunodeficiency virus increases the likelihood of activation of the latent tuberculosis process. The lifetime risk of tuberculosis in non-immunodeficient patients is 5-10%, while in HIV-positive individuals it is about 10% per year.

The recurrence of tuberculosis and the development of its primary forms occur more often in HIV-infected people. Such patients are more susceptible to re-infection with tuberculosis, especially in closed communities and penitentiary institutions.

Against the background of suppression of immunity under the influence of the human immunodeficiency virus, they begin to actively divide in the tissues of the lymph nodes with the development of tuberculous granulomas and caseous necrosis in them. Therefore, lymph nodes are involved in the process, mycobacterium spreads in the body through the lymphogenous route.

Tuberculosis in HIV infection has a pronounced tropism for lymphatic tissue and a progressive course.

The development of the tuberculous process in HIV-infected patients enhances immune suppression, contributing to the progression of other opportunistic infections (candida esophagitis, cryptococcal meningitis, pneumocystis pneumonia), which can be fatal. Therefore, TB has a direct impact on mortality in immunocompromised individuals.

Impact of tuberculosis on the course of HIV infection

The development of TB in AIDS patients also contributes to the emergence of opportunistic infections.

Due to the progression of immunodeficiency and at the level of CD4 cells (T-helpers) less than 50-80/mm3, the ability of the immune system to prevent the recurrence of tuberculosis and its dissemination decreases. Pulmonary localization of tuberculosis infection is the main form in adults, its manifestations depend on the level of immunodeficiency.

The clinical picture of tuberculosis at an early stage of HIV infection is no different from the manifestations in patients without immunodeficiency. In the early stage of HIV infection (CD4 count ≥ 350/mm3), TB is predominant, with bacterial excretion and typical changes in the lung tissue visible on radiographs.

In the late stage (CD4 cell level ≤ 200/mm3), tuberculosis without bacterioexcretion predominates. In the case of the terminal stage of immunodeficiency, the number of extrapulmonary forms increases, including.

Clinical course of co-infection

Features of the clinic of the tuberculosis process in patients with immunodeficiency

Particular attention should be paid to patients:

• with respiratory and toxic symptoms lasting ≥ 2 weeks;
• contact with bacterial excretors in everyday life;
• with the presence of additional risk factors (injection drug addicts, persons who abuse alcohol, stay in penitentiary institutions).

Symptom complexes, in the presence of which it is necessary to test for tuberculosis:

In immunocompromised individuals, pulmonary tuberculosis must be distinguished from other pathologies of the respiratory system, because many diseases can be accompanied by similar clinical manifestations and changes on the x-ray. It is easier to diagnose tuberculosis in the early stages of HIV infection: during this period, bacterial excretion can be detected; later, pulmonary tuberculosis occurs without bacterial excretion and its extrapulmonary forms (including miliary), which are more difficult to detect.

Features of the tuberculous process at various stages of HIV infection

Late in patients with immunodeficiency is associated with its atypical course and clinical features.

The course of tuberculosis in the early stages of HIV infection is similar to the clinical course in persons without immunodeficiency. In the later stages, in 50-60% of patients, tuberculosis has an extrapulmonary localization (tuberculosis of the bones, genitourinary system, skin) and occurs more often when the number of T-helpers is ≤ 200 cells/mm3. Septic forms develop at the level of CD4 cells ≤ 100 cells/mm3.

Tuberculosis does not differ in the incidence of clinical forms in HIV-negative and positive individuals. In patients with immunodeficiency, tuberculosis is diagnosed when it passes into infiltrative, fibrous-cavernous and septic forms.

First of all, this is due to gaps in diagnostics - insufficient coverage of this group by fluorographic examination.

Clinical manifestations of tuberculosis in HIV-infected:

• severe weight loss;
• stable increase in body temperature (≥1 month);
• night sweats;
• weakness, asthenia, drowsiness;
• prolonged cough (dry or with little sputum) (≥3 weeks);
• hemoptysis;

• chest pain, difficulty breathing;
• diarrhea
• decrease in the level of hemoglobin and red blood cells in the blood
• possible enlargement of the liver and spleen
• 30% of patients have generalized lymphadenopathy.

With lymphadenopathy, the anterior cervical, axillary, intrathoracic, less often inguinal lymph nodes increase. They are dense in consistency, bumpy, soldered to the adjacent tissues. In patients without immunodeficiency, the lymph nodes do not increase (the exception is tuberculosis of the lymph nodes).

Features of the course of HIV infection in tuberculosis

In persons without immunodeficiency, due to the preserved reactivity of the body, pulmonary symptoms are more common - destruction of the lung tissue, lesions of the bronchial tree, resulting in cough and hemoptysis. Wasting and fever are typical symptoms for HIV-positive people.

Characteristic signs of the development of tuberculosis in the terminal stage of HIV infection:

1. Long-term persistent increase in temperature up to 39-40 ° C against the background of active anti-tuberculosis therapy;
2. Pronounced emaciation (almost 10 kg within 2-3 months);
3. Liquid, light, up to 400 ml foamy sputum, easily coughed up;
4. Accelerated ESR (> 45 mm/h), leukocytosis up to 20 g/l;
5. X-ray in the lungs, against the background of the localization of the tuberculous process in the upper part, scattered infiltrates are found, mainly in the middle-lower lobes. The process in the lungs progresses rapidly against the background of intensive anti-tuberculosis therapy despite the absence of drug resistance;
6. The presence of candidiasis of the oral cavity;
7. Non-informative tuberculin samples;
8. (80-85%).

The course of AIDS in the form of a mixed infection (combination with pneumocystis pneumonia or cytomegalovirus infection) affects the x-ray picture. In this case, common changes are determined with signs of an increase in the basal peritracheal, mediastinal lymph nodes.

If an extrapulmonary process is suspected, it is best to perform computed tomography. For HIV-infected patients, the development of tuberculous meningitis is characteristic, especially rapidly occurring in young people (18-24 years old).

The localization of the pulmonary process in HIV-infected patients is both typical and middle and lower lobe localization of tuberculous infiltrates, in contrast to patients without immunodeficiency, in whom the localization of the process is always upper lobe. The lower lobe localization of tuberculous infiltrate in HIV-infected people may be the reason for the low level of tuberculosis detection and overdiagnosis of community-acquired pneumonia.

Features of the course of tuberculosis in HIV patients and atypical localization of the process in the lungs can be the reason for late detection and treatment. Immunocompromised patients with long-term symptoms of intoxication should be immediately examined for tuberculosis.

Diagnostics

All patients with HIV infection or tuberculosis should be screened for co-infection. Particular attention should be paid to patients with respiratory and intoxication symptoms.

Examinations for suspected tuberculosis against the background of HIV infection

• Mandatory:

1. collection of complaints and anamnesis;
2. three-time analysis of sputum (or other biological medium) by microscopy with Ziehl-Neelsen staining;
3. survey radiography of the chest;
4. three-time analysis of sputum or other biological environment by seeding.

• Additional:

1. computed tomography of the chest;
2. fiberoptic bronchoscopy with sampling of wash water for microscopic and bacteriological examination;
3. biopsy of the lungs and enlarged lymph nodes;
4. fibroscopic studies in case of suspected damage to specific organs and systems (gastroscopy, laparoscopy, etc.);
5. tuberculin diagnostics (Mantoux test);
6. molecular genetic analysis (polymerase chain reaction method);
7. trial anti-tuberculosis therapy.

Features of the Mantoux test depending on the stage of HIV infection:

Diagnosis of HIV infection in patients with tuberculosis

• collection of complaints and anamnesis of the disease;
• examination of peripheral lymph nodes;
• a detailed clinical blood test with the determination of the leukocyte formula;
• determination of the level of CD4 cells and the ratio of CD4/CD8;
• virological blood test;
• determination of the level of hepatic transaminases and bilirubin in the blood serum (ALT value 3 times higher than normal values ​​will influence the choice of drugs for the treatment of co-infection).

Additional examinations: determination of antibodies to HIV by enzyme immunoassay.

Detection of extrapulmonary tuberculosis is carried out according to the following scheme:

• biopsy of enlarged peripheral lymph nodes with microscopic examination and inoculation of the material for the presence of Koch's bacterium;
• pleural biopsy with fluid culture for the presence of MBT in patients with exudative pleurisy;
• computed tomography of the thoracic and abdominal organs in persons with prolonged fever of unknown origin;
• five urine cultures for the presence of MBT in case of persistent pathological changes in the urine and a positive response to broad-spectrum antibiotics;
• culture of cerebrospinal fluid for the presence of MBT. It should be remembered that the course of tuberculous meningitis can be combined with cryptococcal.

Treatment

Basic principles of co-infection treatment:

• Treatment for active TB is epidemiologically more important than treatment for HIV infection, so co-infection therapy begins with anti-TB drugs
• treatment of tuberculosis in HIV infection is carried out according to the same schemes as in patients without immunodeficiency;
• if the patient is already receiving ART, it is continued, and if necessary, treatment is adjusted taking into account its compatibility with anti-TB drugs;
• after completion of the main course of antimycobacterial therapy (AMBT), prophylactic treatment is not used;
• prophylactic treatment with biseptol prevents death from pneumocystis pneumonia.

Treatment of tuberculosis against the background of immunodeficiency

The main therapy is a long-term continuous combined treatment with anti-tuberculosis drugs in a full daily dose in 1 dose. The standard course is carried out using 4-5 anti-tuberculosis drugs of the first line - isoniazid (H), rifampicin (R), streptomycin (S), pyrazinamide (Z), ethambutol (E).

It includes an intensive phase (2 months to prevent the emergence of multi- and multi-resistant strains of MBT) and a maintenance phase that lasts 4 months. In no case should you skip the daily dose of the drug.

Anti-tuberculosis therapy for HIV infection should be selected taking into account the drug resistance of mycobacteria. In case of resistance, at least 2 main drugs active against the pathogen should be prescribed, and reserve drugs - ciprofloxacin (750 mg 2 r / day) or ofloxacin (400 mg 2 r / day).

Standard regimens for the treatment of patients with pulmonary tuberculosis:

Notes: tuberculosis of the osteoarticular system is treated for 9 months, urogenital system - 10 months, and tuberculous meningitis - 12 months.

Adverse reactions to antimycobacterial drugs

Adverse reactions to anti-TB drugs are more common in HIV-positive individuals than in HIV-negative ones. The risk of drug intolerance increases with increased immunosuppression, against the background of alcohol intake and poor nutrition. Most adverse reactions occur during the first 2 months of treatment.

Side effects of 1st line anti-tuberculosis drugs and methods for their correction:

Treatment of HIV infection against the background of tuberculosis

At the moment, there are no drugs that can cure AIDS, there are only drugs that can slow the progression of the disease and prolong life. For this, antiretroviral therapy (ART) is used.

The goal of treatment is to maximize life extension and improve its quality. Antiretroviral therapy (ART) involves the use of a combination of three antiretroviral drugs (ARVs).

This allows you to suppress the reproduction of HIV as much as possible, reduce the suppression of the immune system. ART plays a significant role because mortality in patients not taking antiviral drugs was higher.

If the level of CD4-lymphocytes>200/mm3, then the appointment of antiretroviral therapy should be postponed until the completion of the course of tuberculosis treatment. In patients with extrapulmonary TB and/or CD4 count< 200/мм3 АРТ следует проводить параллельно с приемом противотуберкулезных препаратов.

In the terminal stage of AIDS, traditional antimycobacterial therapy is ineffective - the prognosis remains unfavorable, as patients die from various infectious complications of AIDS (more often pneumocystis pneumonia).

During treatment, you should follow the instructions of the doctor. In no case should you independently increase or decrease the dose of drugs. If you feel unwell, tell your doctor immediately!

Drug interaction

Rifampicin is the most active drug for the treatment of tuberculosis, therefore it has a number of side effects regarding interactions with other drugs, in particular ART drugs.

Some ART drugs are contraindicated for co-administration with rifampicin (ritonavir). Also, with combination therapy, the concentration of certain antiretroviral drugs in the blood (indinavir, lopinavir, saquinavir) decreases. This should be taken into account in order to increase the dose of the above drugs in order to achieve the desired effect. ART is not recommended during the intensive phase of TB treatment.

Tuberculosis is one of the most dangerous infectious diseases that destroy the lungs. Without a correct diagnosis and timely treatment, the disease leads to death. Despite the availability of modern equipment, rapid diagnosis and new approaches to treatment, lung infection continues to “walk the planet”. But if a person is a carrier of HIV infection, then tuberculosis often accompanies this disease. Let's see why this happens.

The link between HIV and TB

Tuberculosis (TB) is caused by a bacterium called Koch's bacillus or Mycobacterium tuberculosis (TB). It has a lot of differences from other bacteria and is quite difficult to diagnose due to the slow development and reproduction. Mycobacterium is found in the lungs of 1/3 of the world's population, but not everyone suffers from tuberculosis. MBT can be in the lungs without showing itself in any way. But HIV and tuberculosis are an explosive mixture, where one disease accelerates the development of another.

The reasons for the development of TB on the background of HIV is a gradual decrease in immunity. After a few years, the protective barrier of the body almost completely ceases to operate. At this moment, the Koch bacterium is activated, for the development of which ideal conditions have been created, because immunity no longer interferes with its settlement in the lungs. Therefore, when diagnosed with HIV, tuberculosis is also diagnosed after some time.

What is the connection between these two dissimilar infections? HIV increases the development of tuberculosis, and Koch's bacillus spreads beyond the lungs, affecting the spine and lymph nodes. Active TB weakens the body by activating the immunodeficiency virus. Tuberculosis is transmitted to HIV-infected people 7 times more often than to people with a strong immune system.

Tuberculosis bacillus is found in 2 billion people worldwide every year. Every year 3 million people die from tuberculosis. It is a "disease of the poor" that affects the poor living below the poverty line.

Diseases can develop according to the following scenario:

• an HIV patient develops primary tuberculosis;
• both diseases develop in parallel;
• diagnosing the disease against the background of AIDS (the final stage of HIV, when the immune system is completely destroyed).

At the same time, it is possible to “earn two infections” in 10% of cases. The third option is the most dangerous: in the complete absence of an "immune response", Koch's wand begins to behave quite actively, settling not only inside the body, but also leaving it in large quantities, infecting others.

Impact of HIV infection on the development of TB

Tuberculosis is curable, but treatment is long and difficult due to the high resistance (resistance) of bacteria to antibiotics. In the presence of the immunodeficiency virus in the body, the following are noticed:

• difficult diagnosis of pulmonary tuberculosis;
• difficulties in the selection of drugs;
• low cure rate and high mortality rate;
• ineffectiveness of therapy due to the side effects of most drugs;
• high frequency of recurrence of the disease after the course of treatment.

Tuberculosis is transmitted by airborne droplets when sneezing, coughing. An air-dust infection is possible when the patient spits out sputum, and it freezes, but the bacteria in it do not die. They rise with the dust and enter the body of another person.

When in contact with a patient, there is a possibility of infection, but when communicating with an AIDS patient, it increases many times over. At the last stage, all body fluids contain particles of the virus, especially a lot of them in the blood and seminal fluid.

The bacterium Mycobacterium tuberculosis is transmitted from people with active tuberculosis. With a strong immune system, Koch's bacillus practically does not multiply in the lungs and the disease does not develop. In HIV-infected people, the bacterium becomes active after a few months or years.

Dual Illness Signs

Symptoms differ slightly from the usual manifestations of tuberculosis in an organism not affected by the immunodeficiency virus. The manifestation of the disease is directly related to the degree of development of tuberculosis (TB) and the timing of HIV infection. In addition, the symptoms depend on the stability (or instability) of the immune system.

Pathology manifests itself in the following:

• febrile conditions at elevated temperature;
• nocturnal hyperhidrosis (profuse sweating);
• prolonged cough lasting up to 3 weeks;
• allocation of blood masses with and without coughing (at the last stage);
• poor activity of the gastrointestinal tract;
• pain in the chest area;
• significant weight loss (up to 10%):
• damage to the lymph nodes, which are characterized by a tuberous structure, increased size and pain on palpation.

Infectionists are of the unanimous opinion that after receiving a positive result for HIV, the patient should be examined for tubercle bacillus. And if its presence is confirmed, then the phthisiatrician will monitor the course of the disease in dynamics.

There is the concept of atypical tuberculosis, which affects not the lungs, but other organs and tissues, for example, the digestive tract, kidneys, and urethra. In some cases, Koch's wand becomes the "culprit" of meningitis.

Fever, chronic fatigue and rapid weight loss remain the main symptoms of atypical TB. These are universal signs in any form of the disease.

Forms of development of tuberculosis

TB can be latent or active:

1. With a latent and sluggish process, the patient does not experience any particular inconvenience, since the symptoms of the disease are not expressed and it is impossible to determine the pathology by external signs.
2. Active disease usually occurs in HIV-infected people. The signs of the disease are clearly expressed and people around are easily infected from the virus carrier.

The causes or impetus for such active behavior of mycobacteria is childhood or old age, poor nutrition, pregnancy, alcohol or drug use.

When identifying HIV and pulmonary tuberculosis, it is important to carry out the following activities:

• initial examination and confirmation of the presence of TB;
• informing the patient and recommendations;
• registration;
• once every six months - fluorography (computed tomography) and taking a tuberculin test;
• study of sputum released during coughing;
• prescription of anti-tuberculosis therapy.

The patient should carefully monitor the state of health and, at the first sign of malaise, contact the attending physician. If his condition worsens, then urgent hospitalization is required.

Diagnostic measures

After a positive test for HIV, the patient is tested for the presence of Mycobacterium tuberculosis. The most common diagnosis is a tuberculin test (Mantoux test). The test involves injecting a tuberculosis protein under the skin on the wrist. The appearance after 3 days of significant redness at the puncture site indicates the presence of a pathogenic bacterium in the lungs.

But when tuberculosis and HIV infection are combined together, the test does not always give a positive reaction to Koch's bacillus, since the immune system is significantly weakened. Therefore, the test is not a 100% guarantee of determining the disease.

New in medicine are ELISPOT tests that detect lymphocytes that respond to mycobacterium proteins. The test is reliable and fast detection of the disease. There are other methods that determine the activity of bacteria.

Emphasis on X-ray and sputum analysis should not be:

• The radiograph most often looks absolutely normal or indicates other pulmonary diseases, so a CT scan of the lungs is indispensable.
• Cough with sputum in patients with HIV is not always allocated. But even if sputum can be isolated, it will take a long time to grow a bacterium that multiplies slowly both in the body and on a nutrient medium, and treatment must be started immediately.
• Extrapulmonary TB requires tissue samples to properly diagnose the disease.

If it is not possible to isolate sputum, then lung tissue or lymph nodes are needed for analysis. With an inaccurate diagnosis, the doctor prescribes a course of antibiotics and monitors the patient's symptoms.

Features of treatment

Both diseases are complex, the treatment of each individually requires a serious approach. But when pathologies occur simultaneously, then one cannot count on a positive prognosis.

With simultaneous exposure to the Koch bacillus and the human immunodeficiency virus, several antiretroviral drugs are prescribed in combination with anti-tuberculosis chemotherapy, which is carried out in the same mode for HIV patients and AIDS patients.

With intensive chemotherapy, which lasts 2-3 months, the patient receives 4 main anti-tuberculosis drugs: Isoniazid, Rifampicin, Pyrazinamide and Ethambutol. Often they are prescribed simultaneously, but they have serious side effects: headaches, the appearance of drug-induced hepatitis, the impact on the psyche.

The course of the disease is protracted, so treatment can be long - up to 18-22 months, until tests show a decrease in the number of bacteria in sputum and stabilization of pulmonary processes. In addition, the duration of treatment is associated with low drug exposure and frequent relapses, as strains of bacteria that are resistant to the action of a particular drug constantly appear.

The end result of the treatment is related to the competence of the specialist. In a serious condition of the patient, a plan and course of treatment should be thought out in order to bring him out of this condition. Treatment must be aggressive enough to stabilize the progressing disease process.

Due to the high probability of recurrence, an integrated approach is used and preventive measures are taken in several stages. These include chemoprophylaxis and periodic examinations by a TB specialist.

A number of techniques have been developed that are aimed at alleviating the patient's condition and positive dynamics in these serious diseases. When TB develops on its own, it is difficult to cure, but possible. With tuberculosis and AIDS together, the guarantee of recovery is extremely low, so therapy must be of high quality and aggressive.

How many people live, affected by two ailments? The prognosis depends on a number of factors:

• rapid diagnosis of TB: that is why twice a year you need to undergo fluorography;
• forms of the course of the disease (in the latent stage it is difficult to determine it);
• from the stage of the disease;
• the presence of secondary lesions of internal organs.

According to WHO, people with HIV live twice as long as people who have been exposed to two infections at once. Mortality during the first year of treatment is 20%.

Patient Behavior

As with any therapy, the doctor's efforts to cure the patient come to naught if the patient himself does not strive for this, violating the doctor's prescriptions. Such behavior is unacceptable and extremely dangerous if there are two infections in the body at the same time.

The patient must:

• do not violate the regimen of taking medications;
• not to be silent about possible side effects that occur during treatment;
• do not violate the schedule of visiting a TB doctor after treatment;
• do not ignore additional examinations prescribed by the doctor.

The minimum duration of treatment is 6 months, sometimes it lasts 8-9 months, which reduces the risk of relapse (return of the disease) compared with a shorter course of therapy. Based on the specific situation, the doctor adjusts the time frame after which the patient's condition should stabilize.

The therapeutic effect may be complicated by the resistance of Koch's bacillus to antibiotics. It easily mutates (modifies), adapting to new drugs. Therefore, the doctor must constantly adjust the treatment, selecting new drugs and setting the pain for a longer period of remission.

The presence of two dangerous infections in the body requires a strong-willed effort from a person in order to "stay afloat". It may sound trite, but without the right lifestyle, giving up bad habits and 100% compliance with all medical recommendations, it will be very difficult to survive with such a diagnosis.