Poster presentado en HIV in the americas 2015

1. Oscar Malpartida Tabuchi, MD
Division of Infectious Diseases
Guillermo Almenara Hospital,
Lima, Peru
osc.malta@gmail.com
(511)3242983, ext. 44717
Contact Info
P66 18.Oct
Clinical Presentation and Outcomes of HIV-positive Patients
with Diagnosis of Tuberculosis at Guillermo Almenara Hospital
in Lima, Peru
Malpartida Oscar1, Perez Giancarlo1, Rodriguez Rómulo1, Maquera-Afaray Julio1,
Illescas Ricardo1, Rodriguez Lourdes1, Hidalgo Jose1
1 Division of Infectious Diseases, Guillermo Almenara Hospital, Lima, Peru
ABSTRACT
P013 16.Apr
Background. Tuberculosis (TB) continues to be a major cause of morbidity and
mortality in HIV patients globally, and this is particularly true in Peru. Our objectives
are to describe the frequency, clinical characteristics and outcomes of tuberculosis
in HIV/TB co-infected patients at a tertiary care hospital in Lima, and compare these
findings among patients receiving HAART chronically (Group 1), recently started
(Group 2) and not receiving HAART (Group 3).
Materials and Methods. Retrospective review of medical records of HIV patients
diagnosed of TB during 2014 at Guillermo Almenara Hospital in Lima, Peru. Group 1
included patients receiving HAART for >180 days. Short-term mortality was defined
as death during hospitalization or within 30 days post-discharge/diagnosis.
Results. There were 22 cases of TB during the period of study. Affected patients
were mostly men (n=19, 86.4%) with a mean age of 41.7 years, and a mean CD4
count of 79.3 c/ml. Extra-pulmonary presentations predominated (16/22, 72.7%),
and included five ganglionar TB cases (22.7%), 3 multi-systemic (13.6%), 2 pleural
and gastro-intestinal disease (9.1% each). Twenty-one diagnoses were confirmed
microbiologically, 20 of which (95.2%) had drug susceptibility testing: 4 isolates
presented one-drug resistance (mostly INH), 6 isolates were MDR TB and one case
was XDR. There were 5 (22.7%) patients in Group 1, 6 (27.3%) in Group 2 -one
associated to immune reconstitution-, and 11 (50.0%) in Group 3 -associated with
recent diagnosis of HIV/AIDS. Short-term mortality was highest in Group 3 (n=2,
18.2%). Time to TB diagnosis averaged 18.8 days and diagnoses delays were related
to complicated or atypical presentation or lack of access to microbiological
confirmation. No documentation of INH prophylaxis was found in these patients.
Conclusions. TB significantly affected our HIV-positive patients. Short-term mortality
occurred only in patients not receiving HAART. A high proportion (21/22, 95.5%) of
cases had microbiologically confirmed diagnoses, drug resistance was documented
for a elevated proportion of cases (11/20, 55%), higher than other Latin-American
countries.
Introduction, material and methods
CONCLUSIONS
• TB significantly affected HIV-positive patients, with a higher proportion in patients not receiving HAART.
• Short term mortality only occurred in patients not receiving HAART.
• A high proportion of cases in our study had microbiologically confirmed tuberculosis (21/22, 95.5%).
• Drug resistance (for at least one drug) was documented for the majority of cases (11/20, 55%), with and MDR percentage of 30% in our isolates, higher than other Latin
american and European countries.
REFERENCES
- Situación del control de la tuberculosis en las Américas [Internet]. Washington: PAHO; [cited 2014 Feb 22]. Available from: http://www.paho.org/hq/
- Tuberculosis Country profiles [Internet]. Washington: PAHO; [cited 2015 Mar 30]. http://www.who.int/tb/country/data/profiles/en/
- EFSEN, A., SCHULTZE, A., POST, F., PANTELEEV, A., FURRER, H., MILLER, R., SKRAHIN, A., LOSSO, M., TOIBARO, J., GIRARDI, E., MIRO, J., BRUYAND, M., OBEL, N., CAYLá, J., PODLEKAREVA, D., LUNDGREN, J., MOCROFT, A., KIRK, O., TB/HIV STUDY
GROUP, o.. Major challenges in clinical management of TB/HIV co-infected patients in Eastern Europe compared with Western Europe and Latin America. Journal of the International AIDS Society, North America, 17, nov. 2014. Available at:
http://www.jiasociety.org/index.php/jias/article/view/19505
MATERIAL AND METHODS
Retrospective review of medical records of HIV patients during 2014 (who were
either diagnosed of TB since January 1st 2014 until January the 31st 2015), at
Guillermo Almenara Hospital, Lima-Peru. Records where reviewed for history of
Isoniazid prophilaxis and past active tuberculous infection along with time to
diagnosis and clinical outcomes.
Patients with HIV and TB coinfection where assigned to three groups for
description purposes depending on the use of HAART, which were defined as
chronically recieving HAART (Group 1, >180 days of antiretroviral therapy);
recently started (Group 2, <180days) and not receiving HAART (Group 3).
Clinical outcomes were classiffied as favorable (including discharge, follow-up as
an outpatient or transfer to another health facility for treatment) and unfavorable
during the study period (including death and short-term mortality defined as
death during hospitalization or within 30 days from discharge).
RESULTS
INTRODUCTION
Active tuberculosis is a worldwide health issue, particularly true in Peru which is
second in the Americas in the prevalence of this disease and in Drug -resistant
cases. Lima (Capital of Peru and it’s largest city) has the majority of cases in the
country. Essalud provides health coverage to nearly a fourth of the country’s
population (26%) in Perú, and the Almenara Health Network (Red de Salud
Almenara) in Lima provides coverage for 118223 patients (2011), with the
Guillermo Almenara Hospital as the referral center.
The objective of the present study is to describe TB clinical presentation, prevalence
rates, management, drug susceptibility, and outcomes including short term
mortality depending on the chronic , recent or no use of HAART in all HIV patients
during 2014 in Guillermo Almenara Hospital.
Table. Demographics characteristics, clinical presentation, microbiology results
and outcomes of HIV-positive patients diagnosed of tuberculosis.
Variable n (%) Variable n (%)
Cases of tuberculosis
Men
Mean age
Mean CD4 count
Group
1 (regular HAART, >180 d)
Failing HAART regimen
2 (recent HAART, <180 d)
IRIS-associated
3 (no HAART)
Recent diagnosis of HIV/AIDS
Clinical Presentation
Extrapulmonary TB
Ganglionar
Multi-systemic
Central nervous system
Gastro-intestinal
Other
Pulmonary TB
22
19 (86.4)
41.7 yrs
71.3 c/uL
5 (22.7)
2
6 (27.3)
1
11 (50.0)
7*
16
5
3
2
2
4
6
Hospitalization required
INH prophylaxis
Mean time to diagnosis
Microbiological
confirmation*
Positive AFB
(direct examination)
MODS
GRIESS
Genotype MTBDR®
Conventional culture
Resistance testing results
Susceptible
One drug resistance
INH
SM
MDR TB
XDR TB
Outcomes
Short-term mortality
20
None
18.8 dys
21
17
2
2
2
16
20
9
4
3
4
6
1
2
Of 1246 patients in the HIV program in 2014, 22 developed active tuberculosis, of whom most of them
where: male (19/22, 86.4%), had low CD4 counts (less than 200 c/ml, mean= 79.3) and either sexual
promiscuity or being men who have sex with men (MSM) was the risk factor associated with HIV acquisition
for most of them.
Clinical presentation
Of 22 cases of active tuberculosis during the year, 6 (27.3%) where pulmonary and the rest (16/22, 72.7%)
where extrapulmonary which included involvement of lymph nodes in 5 cases, 2 pleural and 2
gastrointestinal each and three diseminated forms (of note 5 cases had two-organ involvement).
Microbiological data
Most of the patients (21/22, 95.5%) in our study had microbiological confirmation of active tuberculosis .
Most of the cases where smear-positive tuberculosis (17/22, 77.3%) , the rest of smear-negative
microbiologically confirmed cases where made by culture (n=4). Only one case (which corresponded to
enteroperitonea TB was diagnosed by adenosine deaminase measured in peritoneal fluid and by clinical
response to treatment.
All but one of the microbiologically confirmed cases (20/21) underwent drug susceptibility testing. Our
isolates presented 4 (20%) cases of single drug resistance isolates (3 cases with Rifampin monoresistance,
and one case to streptomycin); six isolates (30%) were MDR and one (5%) was XDR, the rest of isolates (n=9,
45%) were fully susceptible to first line anti-TB drugs. Of note more than one susceptibility method was
available for three of our isolates (ie. Conventional culture, GRIESS and PCR in one case)*
Time to TB diagnosis had an average of 18.8 days since the beginning of symptoms and delays were related
to complicated or atypical presentations and lack of access to microbiological confirmation.
Outcomes
Among patients in Group 1, five patients (22.7%) developed tuberculosis, all of them had favorable outcome
(discharge with follow-up as an outpatient). We had 6 patients (27.3%) with tuberculosis in Group 2, also all
patients in this group had a favorable outcome, five of them were discharged home and one (an XDR patient)
was transfered to a health care facility to continue his supervised treatment. One patient developed inmune-
reconstitution inflamatory síndrome (IRIS) during antituberculous treatment and HAART.
Finally 11 patients (50.0%) developed tuberculosis, in Group 3, of whom two (2/11, 18.2%) had an
unfavorable outcome resulting in short-term mortality (both died during hospitalization) due to tuberculosis.
Of note , none of the patients who developed tuberculosis in our study were receiving INH prophylaxis.