HIV/TB Co infection: A case presentation Dr Farouk Muhammad Dayyab ( [email_address] ) Government House Clinic Jalingo 18th February, 2009

Synopsis History Examination Assessment Management plan Investigation results Analysis of the History Analysis of Examination findings Comments on the management plan Conclusion Reference

History

Examination

Assessment

Management plan

Investigation results

Analysis of the History

Analysis of Examination findings

Comments on the management plan

Conclusion

Reference

History I 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.

I 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.

Examination A chronically ill looking young man wasted afebrile, anicteric, acyanosed not dehydrated and no pedal edema. No peripheral lymphadenopathy.

A chronically ill looking young man wasted afebrile, anicteric, acyanosed not dehydrated and no pedal edema. No peripheral lymphadenopathy.

Assessment PTB R/O RVI

PTB R/O RVI

Management Plan Pretest councelling for RVS CD4 cell count, E/U/CR, LFT Sputum AFB X 3, CXR Tabs Ciprofloxacin, Metronidazole and Fansidar.

Pretest councelling for RVS

CD4 cell count, E/U/CR, LFT

Sputum AFB X 3, CXR

Tabs Ciprofloxacin, Metronidazole and Fansidar.

Investigation results Seropositive AFB X 3 ( - ve ) CXR- Suggestive CD4 count – 60 PCV – 34% LFT – normal U/E/Cr – normal

Seropositive

AFB X 3 ( - ve )

CXR- Suggestive

CD4 count – 60

PCV – 34%

LFT – normal

U/E/Cr – normal

Plan Commence on DOTS and HAART To Substitute Nevirapine with Efavirenz

Commence on DOTS and HAART

To Substitute Nevirapine with Efavirenz

Analysis of History Missing Aspects Systemic review Past Medical History Drug History *Family and Social History

Systemic review

Past Medical History

Drug History

*Family and Social History

Why Systemic Review in this HIV/TB Patient? HIV is a Multi-Systemic Disease HIV/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)

HIV is a Multi-Systemic Disease

HIV/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 HIV/TB Patient? the chest History of cough, hemoptysis, dyspnoea, chest pain, stridor and hoarseness of the voice BECAUSE: PTB RVI: PCP, CMV Pneumonia, Fungal chest infections(Histoplasmosis, aspergillosis, blastomycosis), Kaposis sarcoma of the lungs, lymphoid interstitial pneumonitis, lymphomas

History of cough, hemoptysis, dyspnoea, chest pain, stridor and hoarseness of the voice

BECAUSE:

PTB

RVI: PCP, CMV Pneumonia, Fungal chest infections(Histoplasmosis, aspergillosis, blastomycosis), Kaposis sarcoma of the lungs, lymphoid interstitial pneumonitis, lymphomas

Why Systemic Review in this HIV/TB Patient? the git History 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: TB: Abdominal TB(TB Ileitis, peritonitis and adenitis) 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.

History 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:

TB: Abdominal TB(TB Ileitis, peritonitis and adenitis)

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 HIV/TB Patient? the cvs History 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: TB: TB pericarditis RVI: HIV cardiomyopathy, vasculitis.

History 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:

TB: TB pericarditis

RVI: HIV cardiomyopathy, vasculitis.

Why Systemic Review in this HIV/TB Patient? the cns History 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: TB: TB Meningitis RVI: Meningoenchephalitis, cranial nerve palsies, peripheral neuropathy, tubercular enchephalitis, cryptococcal meningitis, AIDS-related dementia, progressive multifocal leukoenchephalopathy, seizure disorders, hemiphlegias and paraphlegias.

History 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:

TB: TB Meningitis

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 HIV/TB Patient? the gut History of loin pain, suprapubic pain, frequency, urgency or hesitency, dysuria, oliguria, anuria, polyuria, hematuria, urethral discharge, facial swelling. BECAUSE: TB: Urogenital TB(urethritis, cystitis, etc) RVI: HIV nephropathy, Penile ca., Genital wart, worsening of STI especially syphyllis.

History of loin pain, suprapubic pain, frequency, urgency or hesitency, dysuria, oliguria, anuria, polyuria, hematuria, urethral discharge, facial swelling.

BECAUSE:

TB: Urogenital TB(urethritis, cystitis, etc)

RVI: HIV nephropathy, Penile ca., Genital wart, worsening of STI especially syphyllis.

Why Systemic Review in this HIV/TB Patient? the mss History of muscle, joint, or bone pain, swelling or limitation of movement. BECAUSE: 1. TB: Skeletal Tuberculosis, Potts disease- Tb spondylitis>Gibbus(vertebral collapse)

History 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 this HIV/TB Patient? BECAUSE: Past history of hospital admissions and blood transfusion. Any history of DM which predisposes to TB

BECAUSE:

Past history of hospital admissions and blood transfusion.

Any history of DM which predisposes to TB

Why Drug History in this HIV/TB Patient? BECAUSE: Long term steroid use predisposed to TB To check interactions with HIV/TB drugs to be given. Past history of use of anti TB drugs

BECAUSE:

Long term steroid use predisposed to TB

To check interactions with HIV/TB drugs to be given.

Past history of use of anti TB drugs

Why Family and Social History in this HIV/TB Patient? BECAUSE: Sexual history: promiscuity, STIs Marital History: Previous and Present marriages Alcohol consumption predisposes to TB

BECAUSE:

Sexual history: promiscuity, STIs

Marital History: Previous and Present marriages

Alcohol consumption predisposes to TB

Analysis of Examination 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.

?? 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 Management Plan: the negative sputum AFB in this HIV/TB Patient Sputum 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 )

Sputum 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 Management Plan: the CXR The 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

The 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 Management Plan: the CXR Early HIV disease CD4>500 cell/ul: Typical PTB presentation: Upper lobe infilterates, cavitory changes Low CD4 count: Lower lobe infilterates, intrathoracic adenopathy, widespread reticulonodular lesions affecting all zones HIV infected patients with TB may have a normal chest radiograph.( Francis J Curry National TB centre USA )

Early HIV disease CD4>500 cell/ul: Typical PTB presentation: Upper lobe infilterates, cavitory changes

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

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

Comments on the Management Plan: the LFT, U/E/Cr were within normal limits in this HIV/TB patient Why LFT, U/E/Cr? Metabolism of drugs by the liver Excretion of drugs by the kidney Both HIV and TB can compromise liver and kidney function To know the baseline to monitor drug toxicity.

Why LFT, U/E/Cr?

Metabolism of drugs by the liver

Excretion of drugs by the kidney

Both HIV and TB can compromise liver and kidney function

To know the baseline to monitor drug toxicity.

Comments on the Management Plan: Use of Ciprofloxacin in this Patient Flouroquinolone 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 )

Flouroquinolone 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 Management Plan: Use of 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 )

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 Management Plan: Antihelminths not given to this HIV/TB patient Eradication 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 )

Eradication 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 Management Plan: Patient was commenced on DOTS and HAART substituting Nevirapine with Efavirenz According 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: CD4<200cells/ul CD4 200 – 350 cells/ul CD4>350 cells/ul CD4 not available.

According 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:

CD4<200cells/ul

CD4 200 – 350 cells/ul

CD4>350 cells/ul

CD4 not available.

Comments on the Management Plan: Patient was commenced on DOTS and HAART substituting Nevirapine with Efavirenz CD4<200cells/ul Start TB treatment. Start ART as soon as TB treatment is tolerated.(between 2 weeks and 2 months) EFV regimen is used. EFV is contraindicated in pregnant women or women of child bearing potential without effective contraception.

CD4<200cells/ul

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

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

Comments on the Management Plan: Patient was commenced on DOTS and HAART substituting Nevirapine with Efavirenz CD4 between 200 – 350 cells/ul Start TB treatment for the 2 month intensive phase then commence on ART If patient is severely compromised start the ART earlier.

CD4 between 200 – 350 cells/ul

Start TB treatment for the 2 month intensive phase then commence on ART

If patient is severely compromised start the ART earlier.

Comments on the Management Plan: Patient was commenced on DOTS and HAART substituting Nevirapine with Efavirenz CD4>350 cells/ul 1. Start TB treatment, Defer ART.

CD4>350 cells/ul

1. Start TB treatment, Defer ART.

Comments on the Management Plan: Patient was commenced on DOTS and HAART substituting Nevirapine with Efavirenz CD4 not available : start TB treatment, consider ART.( the internet journal of pulmonary medicine. www.ispub.com )

CD4 not available : start TB treatment, consider ART.( the internet journal of pulmonary medicine. www.ispub.com )

Conclusion HIV/TB co infection will continue to be challenging to both health care providers researchers and patients.

HIV/TB co infection will continue to be challenging to both health care providers researchers and patients.

Selected references Davidsons principles and practice of medicine 19th edition Hutchisons clinical methods 21st edition Training manual for management of malaria in nigeria Oxford handbook of clinical medicine Francis J Curry National TB centre USA www.nationaltbcentre.edu HIV/TB coinfection Basic Facts 2007 Pubmed: probl Tuberk Bolezn 2007(11):225 The internet journal of pulmonary medicine. www.ispub.com NLM Gateway : A service of the U.S. National Institutes of Health

Davidsons principles and practice of medicine 19th edition

Hutchisons clinical methods 21st edition

Training manual for management of malaria in nigeria

Oxford handbook of clinical medicine

Francis J Curry National TB centre USA www.nationaltbcentre.edu

HIV/TB coinfection Basic Facts 2007

Pubmed: probl Tuberk Bolezn 2007(11):225

The internet journal of pulmonary medicine. www.ispub.com

NLM Gateway : A service of the U.S. National Institutes of Health

Thankyou for listening.