Tuberculosis and HIV infection: treatment, prognosis and prevention. Tuberculosis in HIV-infected people - is it possible to make long-term plans? Tuberculosis in HIV-infected people life expectancy

Symptoms, clinical picture and prognosis of tuberculosis depend on the stage of HIV infection and are determined by the degree of impairment of the immune response.

ICD-10 code

B20.0 Disease caused by HIV with manifestations of mycobacterial infection

Clinical classification of HIV infection

1. Incubation stage.
2. Stage of primary manifestations.

Flow options

• A. Asymptomatic.
• B. Acute infection without secondary diseases.
• B. Acute infection with secondary diseases.

1. Subclinical stage.
2. Stage of secondary diseases.

4A. Loss of body weight less than 10%. fungal, viral, bacterial lesions of the skin and mucous membranes, repeated pharyngitis, sinusitis, shingles.

4B. Loss of body weight more than 10%. unexplained diarrhea or fever for more than a month, repeated persistent viral, bacterial, fungal, protozoal lesions of internal organs, localized Kaposi's sarcoma, repeated or disseminated herpes zoster. Phases.

• progression in the absence of antiretroviral therapy, against the background of antiretroviral therapy;
• remission (spontaneous, after antiretroviral therapy, against the background of antiretroviral therapy).

• progression in the absence of antiretroviral therapy, against the background of antiretroviral therapy;
• remission (spontaneous, after antiretroviral therapy, against the background of antiretroviral therapy).

1. Terminal stage.

During the incubation stage of HIV infection, before seroconversion occurs, the virus actively multiplies, which often leads to immunodeficiency. In conditions of a decrease in the body's immune response, those infected with mycobacteria during this period may develop tuberculosis, which is often regarded as a manifestation of the later stages of HIV infection (stages 4B, 4B and 5). therefore, the prognosis is erroneously determined and treatment and clinical observation that do not correspond to these stages are prescribed.

The beginning of the stage of primary manifestations, which occurs in the form of an acute infection, is most often noted in the first 3 months after infection. It can precede seroconversion (the appearance of antibodies to HIV in the blood), therefore, in patients with tuberculosis who are at high risk of HIV infection, it is advisable to repeat the examination after 2-3 months. Clinical manifestations of tuberculosis at this stage of HIV infection do not differ from those in patients not infected with HIV.

Long-term observation of patients who have had tuberculosis in the stage of primary manifestations shows that after a transient decrease in immune status, it is restored and conventional treatment of tuberculosis produces a good effect. After completing the main course of treatment, the general condition of patients often remains satisfactory for many years: there are no relapses of tuberculosis, the immune status does not undergo significant changes, and no other secondary diseases arise. HIV infection during this period may introduce additional clinical manifestations that need to be differentiated from tuberculosis: enlarged lymph nodes, liver, spleen; diarrhea, meningeal symptoms.

The main clinical manifestation of HIV infection in the latent stage is persistent generalized lymphadenopathy. It must be differentiated from tuberculosis of the peripheral lymph nodes. With persistent generalized lymphadenopathy, the lymph nodes are usually elastic, painless, not fused with the surrounding tissue, and the skin over them is not changed. The duration of the latent stage varies from 2-3 to 20 years or more, but on average it lasts 6-7 years.

Under conditions of continuous replication of the virus in the body of a person infected with HIV, the compensatory capabilities of the immune system at the end of the latent stage are reduced and severe immunodeficiency develops. The likelihood of developing tuberculosis again increases, and the more pronounced the immunodeficiency becomes. the more tissue reactions to the causative agent of tuberculosis change: productive reactions are lost, alternative reactions with dissemination of the pathogen become more and more prevalent.

In stage 4A, the first manifestations of secondary diseases characteristic of HIV infection appear. Since immunodeficiency is not expressed during this period, the clinical, radiological and morphological picture, as a rule, does not differ from the picture characteristic of tuberculosis.

In patients in stage 4B, which usually develops 6-10 years after HIV infection, the X-ray picture increasingly acquires atypical features.

In stage 4B, even more pronounced deviations from typical manifestations of tuberculosis appear; generalization of the process is characteristic, often with a complete absence of changes on radiographs of the lungs. Against the background of significant immunodeficiency, other secondary diseases also develop, which further complicates the diagnosis of tuberculosis.

In general, in the late stages of HIV infection (4B, 4B and 5), the structure of forms of tuberculosis is dominated (more than 60%) by disseminated processes and tuberculosis of the intrathoracic lymph nodes.

An X-ray triad is often determined: bilateral focal or focal dissemination, enlargement of three or more groups of intrathoracic lymph nodes, exudative pleurisy, and rapid dynamics of changes in the X-ray picture, both positive and negative, is possible. Decay cavities in the late stages of HIV infection are detected only in 20-30% of cases, which is associated with changes in tissue reactions against the background of severe immunodeficiency.

A clear clinical picture may precede the appearance of dissemination by 4-14 weeks. In some patients, x-rays fail to detect any changes at all. Among the clinical manifestations, the phenomena of severe intoxication predominate: sudden sweating, temperature rises to 39 o C. In some cases, patients are bothered by a painful cough with very scanty sputum; he may be absent. A third of patients have cachexia.

The percentage of bacteria excretors among patients in the “late” stages of HIV infection is no more than 20-35%, which is associated with a decrease in the number of cases of tuberculosis in the decay phase during this period. Tuberculin tests in the “late” stages of HIV infection are in most cases uninformative.

Pathomorphological examination of removed lymph nodes often reveals massive conglomerates with total caseosis.

During morphological examination, predominantly alterative reactions (necrosis) are recorded - 76%. Dissemination is miliary in nature, and in some cases it can only be determined by histological examination. Epithelioid and giant Pirogov-Langhans cells are practically absent, and instead of the caseation typical of tuberculosis, coagulative necrosis and purulent fusion are more often observed. In fingerprint smears from these areas, in the majority of observations (72%), a very large number of Mycobacterium tuberculosis was found, comparable to a pure culture. In this regard, in patients in the late stages of HIV infection (4B, 4B and 5), morphological and bacteriological examination of biopsy specimens is of particular importance for the timely detection of tuberculosis.

Also, to diagnose tuberculosis and other secondary diseases during this period, it is advisable to use the PCR method, which can be used to detect the genetic material of pathogens in the cerebrospinal fluid, pleural fluid, lavage, and biopsy samples.

The difficulty of diagnosing tuberculosis is due to this. that most patients develop other secondary diseases: candidal stomatitis, visceral candidiasis, recurrent herpes, manifest cytomegalovirus infection, HIV-associated encephalopathy, Kaposi's sarcoma, cerebral toxoplasmosis, pneumocystosis, cryptococcosis, aspergillosis.

The effect of treatment during this period depends on the timely detection of atypical tuberculosis and the prescription of adequate therapy. If tuberculosis is not detected in a timely manner, the process generalizes and treatment is ineffective.

Detection of tuberculosis in patients with HIV infection

It is recommended that immediately after the diagnosis of HIV infection, before the development of severe immunodeficiency, patients who are at high risk of tuberculosis are identified for subsequent dynamic monitoring of them by a TB specialist, who in the later stages of HIV infection, when immunodeficiency develops, could promptly prescribe preventive or primary course of treatment for tuberculosis.

To identify people at high risk of developing tuberculosis due to HIV infection, the following activities are carried out:

• All newly diagnosed patients with HIV infection must be examined by a TB specialist, noting in the outpatient card a detailed history regarding the increased risk of tuberculosis. The patient is informed about tuberculosis and measures to prevent it and is recommended that if symptoms characteristic of tuberculosis appear, he should immediately go to a phthisiatrician for an unscheduled examination and examination:
• immediately upon registration and then 1-2 times a year (depending on the degree of risk of tuberculosis and the stage of HIV infection, radiology diagnostics of the chest organs is carried out (an X-ray archive is created for the patient);
• When registering patients for HIV infection, a tuberculin test (2 TU) is performed, and then during the period of dynamic observation it is given 1-2 times a year (depending on the degree of risk of tuberculosis and the stage of HIV infection with the results recorded in the card dispensary observation.

During the period of dynamic observation of patients with HIV infection, if hyperergy, a turn or an increase in the reaction to tuberculin is detected, the phthisiatrician individually, taking into account the stages of HIV infection and objective data, decides on prescribing anti-tuberculosis drugs to the patient.

In persons. secreting sputum, it is examined for the presence of Mycobacterium tuberculosis. In the event of the appearance of clinical or laboratory manifestations of extrapulmonary tuberculosis, if possible, a bacteriological examination of the corresponding discharge and/or other indicated examination methods are carried out.

All patients with HIV infection at risk of tuberculosis who are hospitalized due to a deterioration in their general condition must be examined by a TB specialist.

Dispensary observation of patients suffering from HIV infection from a high-risk group for tuberculosis (but without clinical manifestations) is carried out by a TB specialist in the diagnostic screening room at the AIDS center. The organization of such an office in an anti-tuberculosis institution will lead to the fact that patients with immunodeficiency will come to the site of tuberculosis infection.

Patients with symptoms of tuberculosis are referred to the reference diagnostic room at the anti-tuberculosis dispensary. The essence of organizing such an office is to have a separate entrance to it. Thus, the intersection of epidemiologically dangerous tuberculosis patients and patients with immunodeficiencies of various origins who come to the tuberculosis dispensary for examination is minimized.

Screening examination for tuberculosis in patients with HIV infection

In the early stages of HIV infection, tuberculosis has a typical course, so screening during this period is carried out in the same way as for people without it.

Indications for extraordinary tuberculosis diagnostics in children are given in Appendix G4 to the Order of the Ministry of Health of Russia dated March 21, 2003 M2 109 “On improving anti-tuberculosis measures in the Russian Federation.”

In conditions of immunodeficiency beginning to develop in patients with HIV infection, the likelihood of contracting tuberculosis increases, and therefore there is a need to increase the frequency of screening examinations and introduce additional methods of examination for tuberculosis.

Formulation of diagnosis for tuberculosis combined with HIV infection

When identifying tuberculosis in patients with HIV infection, a complete clinical diagnosis should include:

• stage of HIV infection;
• detailed diagnosis of tuberculosis and other secondary diseases. For example, if a patient with HIV infection in the stage of primary manifestations (it lasts a year from the onset of acute infection or seroconversion) develops tuberculosis due to a transient decrease in immune status, then a diagnosis of HIV infection is made. stage of primary manifestations (PM).

This is followed by a detailed diagnosis of tuberculosis (the presence or absence of bacterial excretion is noted) and other secondary, and then concomitant diseases. The clinical classification of tuberculosis used to formulate its diagnosis is presented in the annex to the Order of the Ministry of Health of Russia dated March 21, 2003 No. 109 “On improving anti-tuberculosis measures in the Russian Federation.”

If a patient with HIV infection, after completing the stage of primary manifestations and in the absence of any clinical symptoms indicating a deficiency of the immune system (or laboratory manifestations of immunodeficiency), develops a limited tuberculosis process, it is inappropriate to consider it as a secondary disease. In such a case, the latent stage of HIV infection is indicated in the diagnosis.

Tuberculosis in patients with HIV infection, which developed after the completion of the stage of primary manifestations, indicates the stage of secondary diseases in the presence of one of the following factors:

• severe immunodeficiency confirmed by laboratory methods (CD4
• dissemination of the tuberculosis process;
• a significant decrease in reactivity recorded during morphological examination of tissues involved in the tuberculosis process (for example, a lymph node).

Treatment of tuberculosis in patients with HIV infection

Treatment of tuberculosis in patients with HIV infection includes two directions.

• Organization of controlled treatment of tuberculosis in patients with HIV infection.
  • The diagnosis of tuberculosis in patients with HIV infection is confirmed by the phthisiatric CVCC, which includes a doctor who has specialized in HIV infection and knows the peculiarities of the course of tuberculosis in the late stages of HIV infection.
  • Treatment of tuberculosis in patients with HIV infection is carried out in accordance with standard tuberculosis treatment regimens approved by the Russian Ministry of Health, but taking into account the peculiarities of treatment of this pathology in patients with HIV infection.
  • During chemotherapy, medical personnel monitor the intake of anti-tuberculosis and antiretroviral drugs by patients
  • After completion of the main course of treatment for tuberculosis, clinical observation of patients is continued by a phthisiatrician specializing in HIV infection in order to prevent relapse of the disease.
• Highly active antiretroviral therapy.
• Creation of a system of psychological and social adaptation of patients with tuberculosis combined with HIV infection.
  • Conducting routine and crisis counseling for patients, their relatives or loved ones by a psychotherapist at a territorial AIDS center.
  • Before starting treatment, it is necessary to conduct a conversation with the patient, the purpose of which is to morally support the patient, explain the difference between the early and late stages of HIV infection, convince him of the need for immediate long-term treatment in a specialized hospital, orient him to continue living in the family, with relatives and friends people, possible work activities. The patient must be informed about the routes of transmission of both infections, measures to prevent them, and rules of communication with sexual partners. During the treatment process, a patient with tuberculosis and HIV infection must be constantly provided with psychological support in order to reinforce the attitude towards strict adherence to the treatment regimen and abstinence from taking drugs and alcohol.
  • Comprehensive advisory assistance from a social worker at a territorial AIDS center to patients, their relatives or loved ones on issues of employment, housing, various benefits, etc.

The location of inpatient care for patients with tuberculosis combined with HIV infection depends on its stage and prevalence in the constituent entity of the Russian Federation.

In a small number of cases of combined pathology in a constituent entity of the Russian Federation, inpatient treatment of patients with tuberculosis in the stage of secondary diseases is carried out by a specialist in HIV infection, but always with the advice of a highly qualified phthisiatrician. This is because, in addition to treating tuberculosis in these patients, treatment for HIV infection and diagnosis and treatment of other secondary diseases are necessary. At the same time, all anti-epidemic measures regarding tuberculosis infection must be observed.

In the early stages of HIV infection (2,3,4A), these patients are treated by TB specialists with mandatory consultations with an HIV specialist.

When HIV infection is detected for the first time in patients receiving inpatient treatment in a tuberculosis facility, an epidemiological investigation of the case of HIV infection is required. To do this, the center for the prevention and control of AIDS in a constituent entity of the Russian Federation, taking into account local conditions, must determine the procedure for its implementation in an anti-tuberculosis institution and the specialists responsible for the timeliness and quality of this work.

When there is a high need for the treatment of combined pathology in a constituent entity of the Russian Federation, a specialized department is created, the staff of which includes phthisiatricians and infectious disease specialists.

Indications for antiretroviral therapy

Goals of highly active antiretroviral therapy (HAART):

• life extension;
• maintaining quality of life in patients with asymptomatic infection;
• improving the quality of life in patients with clinical manifestations of secondary diseases;
• prevention of the development of secondary diseases;
• reducing the risk of HIV transmission.

When deciding whether to prescribe HAART, the inadequate implementation of which is associated with the risk of the formation of drug-resistant virus strains, in addition to medical criteria, it is necessary to take into account socio-psychological ones, such as the patient’s readiness and ability to undergo the prescribed treatment in full. If necessary, it is necessary to stimulate the patient's interest in therapy (counseling, psychosocial support, etc.). select the most convenient medication regimen for him. Before prescribing HAART, the patient signs an informed consent.

The presence of HIV infection in itself is not an indication for HAART. Prescribing it too early is inappropriate, and too late gives worse results.

Absolute readings;

• clinical: stages 2B, 2B or 4B, 4B in the progression phase;
• laboratory: CD4 count less than 0.2x10 9 /l. Relative readings:
• clinical: stage 4A (regardless of phase). 4B, 4B in remission phase;
• .laboratory: CD4 count equal to 0.2-0.35x10 9 /l, HIV RNA level (“viral load”) more than 100 thousand copies in 1 ml.

If there are relative indications, some experts and guidelines recommend starting therapy, and some recommend continuing to monitor the patient without prescribing treatment. In this situation, the Federal Scientific and Methodological AIDS Center recommends. begin treatment if the patient has an active desire and is confident in his good adherence to treatment, as well as if both clinical and laboratory relative indications for therapy exist simultaneously.

The level of CD4 lymphocytes and HIV RNA are taken into account as indications for prescribing HAART, if within a month before their assessment the patient had no diseases accompanied by inflammatory processes and no vaccinations.

If laboratory. indications for prescribing HAART are identified for the first time, and there are no clinical indications for starting therapy, then repeated studies are necessary to decide on treatment:

• with an interval of no less. 4 weeks if the CD4 level is less than 0.2x10 9 /l;
• with an interval of at least 1.2 weeks with a CD4 count of 0.2-0.35x10 /l.

When prescribing HAART according to clinical indications, it should be taken into account that in persons taking psychotropic drugs, fungal and bacterial lesions (lesions of the skin and mucous membranes, abscesses, cellulitis, pneumonia, endocarditis, sepsis, etc.) more often develop not as a consequence of HIV- infections, but as a manifestation of immunodeficiency associated. with drug use. In these cases, to prescribe HAART, it is necessary to examine the number of CD4 lymphocytes.

It is recommended to start HAART in most patients with regimens containing, in addition to two drugs from the group of nucleoside reverse transcriptase inhibitors of HIV. one drug from the group of non-nucleoside HIV reverse transcriptase inhibitors. However, if a patient has HIV infection in stage 4B (progression phase), the level of CD4 lymphocytes is less than 0.05x10 9 /l or the amount of HIV RNA is more than 1 million copies per 1 ml, it is recommended to start therapy with regimens containing one drug from the group of protease inhibitors HIV and two drugs from the group of nucleoside reverse transcriptase inhibitors of HIV.

First-line active antiretroviral regimens

• efavirenz 0.6 g once a day + zidovudine 0.3 g 2 times or 0.2 g 3 times a day + lamivudine 0.15 g 2 times a day.

For some patients, the standard HAART regimen cannot be prescribed (primarily due to the range of side effects of the drugs included in it), in particular:

• Efavirenz is contraindicated in pregnant women and women planning (or not excluding) pregnancy and childbirth while on antiretroviral therapy. This drug is not recommended for women of childbearing potential who do not use barrier methods of contraception, or for people who work at night;
• Zidovudine is not recommended for use in patients with anemia and granulocytopenia. When hemoglobin levels are less than 80 g/l, stavudine may be included in the HAART regimen instead of zidovudine.

If absolute or relative contraindications to any of the drugs recommended for the standard regimen are identified, changes are made to it.

If a patient has an alanine aminotransferase level corresponding to grade 2 toxicity or more, it is recommended to use HAART regimens with HIV protease inhibitors.

Alternative first-line HAART regimen:

• lopinavir + ritonavir 0.133/0.033 g, 3 capsules 2 times a day + zidovudine 0.3 g 2 times or 0.2 g 3 times a day + lamivudine 0.15 g 2 times a day.

• nelfinavir 1.25 g 2 times a day + zidovudine 03 g 2 times or 0.2 g 3 times a day + lamivudine 0.15 g 2 times a day.

Frequency of laboratory tests to assess the effectiveness and safety of HAART:

• HIV RNA level and CD4 lymphocyte count - 1 and 3 months after the start of HAART, then once every 3 months;
• clinical blood test - after 2 weeks. 1 month, 3 months after starting HAART, then once every 3 months;
• biochemical blood test - 1 and 3 months after the start of HAART, then once every 3 months;
• in the presence of chronic viral hepatitis - the first ALT study 2 weeks after the start of HAART.

Features of highly active antiretroviral therapy in patients with tuberculosis

Some experts recommend postponing HAART until you finish taking anti-tuberculosis drugs: in this case, patient management is simplified, both infections are treated according to standard regimens, and the side effects of the drugs do not increase. However, in patients with low CD4 counts, delaying initiation of HAART can lead to new complications of HIV infection and even death. Therefore, for patients with tuberculosis with a very high risk of progression of HIV infection (with a CD4 lymphocyte count of less than 0.2 10 9 /l or generalization of the tuberculosis process), it is recommended not to delay the initiation of HAART.

Adverse events when using anti-tuberculosis drugs, as a rule, develop in the first 2 months of treatment. In this regard, it is recommended to start HAART between 2 weeks and 2 months after the start of anti-tuberculosis treatment. depending on the number of CD4 lymphocytes.

Patients with tuberculosis should be prescribed the main recommended or alternative HAART regimen.

Alternatives to efavirenz include saquinavir/ritonavir (400/400 mg twice daily or 1600/200 mg once daily), lopinavir/ritonavir (400/100 mg twice daily) and abacavir (300 mg twice daily). .

Instead of efavirenz, if there are no other alternatives, nevirapine (200 mg once daily for 2 weeks then 200 mg twice daily) can also be used as part of the following regimens: stavudine + lamivudine + nevirapine or zidovudine + lamivudine + nevirapine.

Metabolism of HIV protease inhibitors

Rifamycins (rifabutin and rifampicin) induce the activity of cytochrome P450 enzymes that metabolize non-nucleoside reverse transcriptase inhibitors and HIV protease inhibitors, and, therefore, reduce the serum concentrations of these antiretroviral drugs. In turn, these two groups of antiretroviral drugs, through the same mechanism, increase serum concentrations of rifabutin and rifampicin. Thus, drug interactions can lead to ineffectiveness of antiretroviral drugs and increased toxicity of anti-tuberculosis drugs. The anti-tuberculosis drug rifabutin can be used together with all HIV protease inhibitors (except saquinavir) and with all non-nucleoside reverse transcriptase inhibitors of HIV. if you periodically adjust its dose.

Tuberculosis and motherhood

Pregnancy and childbirth are accompanied by restructuring of the functions of the endocrine system, changes in immunity, metabolism and are risk factors for tuberculosis. The incidence of pregnant and postpartum women is 1.5-2 times higher than the general incidence of tuberculosis in women. Tuberculosis can develop during any period of pregnancy, but more often in the first 6 months after childbirth; tuberculosis that occurs in women during pregnancy and in the postpartum period is usually more severe than that diagnosed before pregnancy.

Tuberculosis first occurring during pregnancy

Women who contract tuberculosis during pregnancy are diagnosed with various forms of pulmonary tuberculosis.

In young, previously uninfected women exposed to primary infection with Mycobacterium tuberculosis, primary tuberculosis is often diagnosed.

More often, endogenous tuberculosis infection is reactivated. In this case, disseminated tuberculosis or various forms of secondary tuberculosis are diagnosed. A severe course of the disease with severe tuberculosis intoxication can have an adverse effect on the development of the fetus and lead to spontaneous miscarriage.

In the first trimester of pregnancy, the initial manifestations of tuberculosis, caused by moderate intoxication (weakness, malaise, loss of appetite, weight loss), are often associated with toxicosis of pregnancy. In the second half of pregnancy, tuberculosis, despite pronounced morphological changes in the lungs, also often occurs without pronounced clinical symptoms, which significantly complicates its detection.

The development of tuberculosis during pregnancy may be associated with HIV infection. In these cases, tuberculosis is found not only in the lungs, but also in other organs.

The effect of pregnancy on tuberculosis

Not all women develop exacerbation of tuberculosis during pregnancy. Tuberculosis rarely activates in the phases of compaction and calcification, and vice versa, there is a sharp increase or progression in the phases of the active process. Particularly severe outbreaks occur in patients with fibrocavernous tuberculosis. The most dangerous for exacerbation of tuberculosis are the first half of pregnancy and the postpartum period. Outbreaks in the postpartum period are especially malignant.

The influence of tuberculosis on the course of pregnancy and childbirth

In severe destructive or disseminated forms of tuberculosis, as a result of intoxication and oxygen deficiency, toxicosis of the first and second halves of pregnancy often develops, and premature birth occurs more often. In newborns, the physiological decrease in body weight is more pronounced and its recovery is slower. Timely administration of specific therapy allows you to bring pregnancy to a successful birth and avoid exacerbations of the postpartum period.

Diagnosis of tuberculosis in HIV infection

Tuberculosis in pregnant women is detected during examination regarding complaints of weakness, fatigue, excessive sweating, loss of appetite, weight loss, low-grade fever, as well as cough - dry or with sputum, shortness of breath, chest pain. If such complaints arise, the obstetrician-gynecologist at the antenatal clinic should refer the patient to an anti-tuberculosis dispensary. At the dispensary, a Mantoux test with 2 TE PPD-L is performed, and clinical blood and urine tests are performed. If sputum is present, it is examined for Mycobacterium tuberculosis using bacterioscopic and bacteriological methods, additionally using PCR.

X-ray examination during pregnancy is carried out in difficult diagnostic situations as an exception, protecting the fetus with a lead shield or apron.

If tuberculosis is suspected or the diagnosis is confirmed, family members of the pregnant woman are examined.

Management of pregnancy in a patient with tuberculosis

In most cases, tuberculosis is not a reason for abortion. Complex anti-tuberculosis therapy often allows you to maintain pregnancy without compromising the health of the mother and child. Pregnancy is usually maintained in patients with active pulmonary tuberculosis without destruction and bacterial excretion, with tuberculous pleurisy, as well as in women who have previously undergone surgical interventions for pulmonary tuberculosis without complications.

Indications for termination of pregnancy in patients with tuberculosis are as follows:

• progressive course of newly diagnosed pulmonary tuberculosis, tuberculous meningitis, miliary tuberculosis:
• fibrous-cavernous, disseminated or cirrhotic pulmonary tuberculosis:
• pulmonary tuberculosis in combination with diabetes mellitus, chronic diseases of other systems and organs with severe functional disorders (pulmonary-cardiac, cardiovascular, renal failure);
• pulmonary tuberculosis, which requires surgical intervention.

Pregnancy should be terminated with the woman's consent within the first 12 weeks. During the period of preparation and after termination of pregnancy, it is necessary to intensify anti-tuberculosis therapy. Repeated pregnancy is recommended no earlier than after 2-3 years.

Pregnant women with an established diagnosis of tuberculosis are registered and are under the supervision of a local phthisiatrician and obstetrician-gynecologist. If progressive tuberculoma, cavernous or fibrous-cavernous tuberculosis with bacterial excretion is detected in a pregnant woman, the possibility of surgical intervention on the lung in order to quickly stop bacterial excretion cannot be ruled out.

For childbirth, a woman with tuberculosis is sent to a special maternity hospital. If there is no such maternity hospital. The obstetrician-gynecologist and TB specialist must notify the maternity ward in advance in order to take organizational measures to prevent the patient from contacting healthy women in labor. Childbirth in patients with active tuberculosis is often more difficult than in healthy women, with greater blood loss and other complications. In case of pulmonary tuberculosis with pulmonary heart failure, in the presence of artificial pneumothorax, surgical delivery by cesarean section is advisable.

Intrauterine infection of the fetus with Mycobacterium tuberculosis occurs rarely; the mechanisms of such infection are hematogenous through the umbilical vein or aspiration of infected amniotic fluid. After birth, contact of a child with a mother with tuberculosis is very dangerous in terms of primary infection with Mycobacterium tuberculosis and tuberculosis disease.

Management of newborns with tuberculosis and HIV infection

Management of a child born from a mother with tuberculosis:

• If a pregnant woman is sick with active tuberculosis, regardless of the isolation of Mycobacterium tuberculosis, the following measures are taken:
  • doctors in the maternity ward are notified in advance of the presence of tuberculosis in a woman in labor;
  • the woman in labor is placed in a separate box;
  • immediately after birth, the child is isolated from the mother;
  • transfer the child to artificial feeding;
  • the child is vaccinated with BCG;
  • the child is separated from the mother for the period of immunity formation - for at least 8 weeks (the child is discharged home to relatives or placed in a specialized department if indicated);
  • if there are contraindications to vaccination or the impossibility of separation, the child is given chemoprophylaxis;
  • before discharge, an examination of the child’s future environment is carried out;
  • Before discharge, all premises are disinfected;
  • the mother is hospitalized for treatment.
• If the child was in contact with the mother before the administration of the BCG vaccine (birth of a child outside a medical facility, etc.). carry out the following activities:
  • the mother is hospitalized for treatment, the child is isolated from the mother,
  • vaccination against tuberculosis is not carried out,
  • the child is prescribed a course of chemoprophylaxis for 3 months;
  • after chemoprophylaxis, a Mantoux reaction is performed with 2 TE;
  • in case of a negative Mantoux reaction with 2 TE, BCG-M vaccination is carried out;
  • After vaccination, the child remains separated from the mother for at least 8 weeks.
• If the tuberculosis dispensary was not aware of the presence of tuberculosis in the mother and tuberculosis was detected after the child was given the BCG vaccine, the following measures are taken:
  • the child is separated from the mother;
  • the child is prescribed preventive treatment regardless of the timing of administration of the BCG vaccine;
  • Such children are under close supervision in the anti-tuberculosis dispensary as the most threatened risk group for tuberculosis.

A postpartum woman undergoes an X-ray examination of her lungs 1-2 days after birth and, taking into account bacteriological data, further tactics are determined regarding the possibilities of breastfeeding and the necessary treatment.

Breastfeeding of newborns is allowed only to mothers with inactive tuberculosis who do not secrete Mycobacterium tuberculosis. The mother should not take anti-tuberculosis drugs at this time, so as not to affect the formation of immunity after the child is vaccinated with BCG.

Treatment of tuberculosis in pregnant women with HIV infection

Treatment of tuberculosis in pregnant women, as well as in nursing mothers, is carried out in accordance with standard chemotherapy regimens and individualization of treatment tactics. When choosing drugs you need to consider:

• possible adverse reactions to aminosalicylic acid and ethionamide in the form of dyspeptic disorders, therefore they should not be prescribed for toxicosis of pregnancy;
• embryotoxic effect of streptomycin and kanamycin, which can cause deafness in children whose mothers were treated with these drugs;
• possible teratogenic effect of ethambutol, ethionamide.

The least dangerous for the pregnant woman and the fetus is isoniazid. It should be prescribed for therapeutic purposes and to prevent exacerbations of tuberculosis.

It is important to know!

Currently, thanks to the increased resistance of the human body to tuberculosis, the widespread implementation of specific vaccination and BCG revaccination, and timely diagnosis of primary tuberculosis infection in childhood and adolescence, hematogenously disseminated tuberculosis is rare.

Identification of a patient with widespread and rapidly developing tuberculosis is a signal that targeted testing for HIV infection will be required. Patients with AIDS should be considered as potentially having any form of lung disease. Tuberculosis and HIV require the earliest possible start of a recovery course and long-term prevention.

Epidemic processes associated with HIV infection have made and are continuously making significant changes in the epidemiological background of tuberculosis. The main impact of HIV infection is the rate of development of clinically expressed tuberculosis in people previously infected with MVT or who have developed AIDS. Tuberculosis and HIV infection can be combined in several variations, the treatment of which is carried out in different ways:

• initial infection with tuberculosis in HIV-infected patients;
• synchronous encounter with HIV infection and tuberculosis;
• formation of a tuberculosis algorithm due to the occurrence of immune deficiency during HIV infection (this may be AIDS).

People infected with both tuberculosis and HIV are especially at increased risk of developing a pathological process.

They have an annual tendency to develop tuberculosis, which is 10%. For other members of the population, this probability does not exceed 5% throughout their entire life course, and treatment may not be necessary.

The main thing about pathology

HIV infection and AIDS significantly affect the state of immune reactivity in tuberculous lesions of the lungs and other systems. Within the framework of the presented process, relationships may change in the process of immune activation at the cellular level, differentiation of macrophages and the formation of special tissue of a granulation nature are identified.

In accordance with this, a more frequent formation of tuberculous lesions in HIV-infected people (the same is true for those infected with AIDS) can be observed in several cases. This may occur due to a decrease in the degree of resistance to initial or secondary infection with MBT (an exogenous route of infection, the treatment of which is most problematic). This can be influenced by the reactivation of old changes after tuberculosis, the worsening of anti-tuberculosis immunity (reactivation based on endogenous characteristics).

Symptoms of the condition

The main manifestations of tuberculosis due to HIV infection should be considered asthenia, permanent or intermittent fever. Prolonged coughing, a significant decrease in body weight, bouts of diarrhea and an increase in the size of the lymph nodes may occur. Most often, the latest changes affect the cervical and axillary nodes, and to the least extent, the inguinal nodes. It is important to pay attention to the fact that the lymph nodes acquire a dense consistency, become lumpy and practically do not move during palpation.

The severity of symptoms of tuberculosis in HIV-infected and AIDS patients is directly dependent on the nature and suppression of cellular immunity. In order to facilitate future treatment and minimize the likelihood of complications, it is necessary to have complete information about additional symptoms.

More about symptoms

More obvious clinical symptoms are identified in patients whose tuberculosis has developed due to HIV infection.

It should be noted that:

• this happens less frequently than in patients with tuberculosis, who subsequently became infected with HIV and faced such a terrible disease as AIDS;
• symptoms associated with tuberculosis, when the lymphocyte ratio remains sufficiently high, may remain the most characteristic and cannot be differentiated in any way from the manifestations and X-ray findings in HIV-negative patients;
• at the last stage, standard manifestations associated with the pulmonary form of tuberculosis predominate in patients.

A prerequisite before starting treatment and starting prevention is to carry out a diagnostic examination. The patient’s health status and other vital processes depend on its timeliness and correctness.

Diagnostic measures

Identification of tuberculosis in HIV-infected people and those who have developed AIDS is carried out based on conventional methods. They refer to a mandatory clinical examination and consist of a detailed study of the patient’s complaints and medical history. The next stage is an objective examination, blood and urine testing for the presence of problematic components.

Next, radiography is carried out, in which the chest organs are examined, and there is a need for repeated examination of sputum using a microscope and its culture for the presence of nutrient media. An intra-epidermal Mantoux test, ELISA of antibodies and tuberculosis-type antigens are assessed.

Difficulties in diagnosing the tuberculosis condition arise at the stage of secondary symptoms, in particular with AIDS. The presence at the presented stage of disseminated and extrapulmonary forms with a sudden decrease in the number of situations of decay of pulmonary tissue reduces the number of patients. At the same time, MBTs, the treatment of which is most problematic, are identified in their sputum during examination with a microscope (using the Ziehl-Neelsen method) and as part of culture.

Rehabilitation course

Chemotherapy for tuberculous lesions that have spread to the respiratory system in HIV-infected people is the most effective. It should be noted that:

• the standard aspect of therapy for patients with tuberculosis and AIDS should be considered the simultaneous use of a certain amount of antiretroviral drugs;
• the use of similar drugs is a mandatory element that is necessary when treating tuberculosis with long-term forms of infection;
• the total duration of the recovery course is identified by the moment the release of bacteria stops and the normalization of all processes in the pulmonary area.

Considering the likelihood of low effectiveness of combining “spare” drugs and the possibility of relapses of tuberculosis lesions (provoked by multiple and stable MBT processes), therapy with chemically active drugs is carried out for at least 18-22 months. In order for treatment to be 100% effective, correct and complete prevention is required.

Preventive actions

When HIV and tuberculosis are connected, special prevention is required. It cannot be limited only to proper nutrition and a special diet, although this measure is mandatory.

In order to achieve success in the recovery process, you should take vitamin and mineral complexes, consume the maximum amount of seasonal vegetables and fruits, berries.

It is important to completely eliminate bad habits and lead a healthy lifestyle. This means daily walking, morning exercises and contrast showers. In some cases, it is permissible to resort to hardening the body. To monitor your health status and the degree of success of treatment, it is necessary to undergo diagnostic examinations and consultations with a pulmonologist and phthisiatrician.

It is important to pay attention to the fact that preventive measures, like treatment, must be long-term. We are not talking about 12-16 months, but about two or more years. With such an integrated approach, which must be combined with a rehabilitation course, success will be achieved. However, one should not discount the danger of HIV and the impossibility of stopping the presented process.

Tuberculosis in HIV-infected people is undoubtedly a dangerous process. However, subject to early diagnosis and correct recovery course, it will be possible to stop it. This will avoid complications and other critical consequences, the treatment of which is problematic in the long-term nature of the course.

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

It is diagnosed in the following cases:

• tuberculosis in 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 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 pressing this problem is and how to deal with it.

The immunodeficiency virus increases the likelihood of activation of the latent tuberculosis process. The risk of tuberculosis in patients without immunodeficiency is 5-10% over a lifetime, while for HIV-positive individuals it is about 10% per year.

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

Against the background of suppressed immunity under the influence of the immunodeficiency virus, people begin to actively divide in the tissues of the lymph nodes with the development of tuberculous granulomas and caseous necrosis. Therefore, the lymph nodes are involved in the process, and the 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 tuberculosis process in HIV-infected patients increases immune suppression, contributing to the progression of other opportunistic infections (candidal esophagitis, cryptococcal meningitis, Pneumocystis pneumonia), which can lead to death. Therefore, tuberculosis has a direct impact on the mortality rate in people with immunodeficiency.

The influence 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 when the level of CD4 cells (T helper cells) is less than 50-80/mm3, the ability of the immune system to prevent relapse 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 the early stage of HIV infection is no different from the manifestations in patients without immunodeficiency. In the early stage of HIV infection (with CD4 cell count ≥ 350/mm3), TB with bacterial excretion and typical changes in lung tissue visible on radiographs is mainly encountered.

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

Clinical course of co-infection

Clinical features of the tuberculosis process in patients with immunodeficiency

Particular attention should be paid to patients:

• with respiratory and intoxication symptoms lasting ≥ 2 weeks;
• contact with bacteria-releasing agents in everyday life;
• with the presence of additional risk factors (injecting drug addicts; alcohol abusers; stay in penitentiary institutions).

Symptom complexes, the presence of which requires examination for tuberculosis:

In people with immunodeficiency, pulmonary tuberculosis must be distinguished from other respiratory pathologies, because many diseases can be accompanied by similar clinical manifestations and X-ray changes. 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 course of the tuberculosis process at various stages of HIV infection

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

Stage of immunodeficiency	Features of the tuberculosis process
I - II stage	Typical course of pulmonary TB: infiltrative-focal, fibrous-cavernous form in the upper lobes with bacterial excretion.
Stage III	Atypical course of pulmonary TB: lesions in the lower parts, absence of fibrous-cavernous form, without bacterial excretion. MBTs are detected in the affected organs. Extrapulmonary forms of TB.
IV stage	Tuberculosis is septic in nature: blood culture reveals MBT (miliary tuberculosis, tuberculous meningitis)

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

The incidence of clinical forms of tuberculosis does not differ between HIV-negative and positive individuals. In patients with immunodeficiency, tuberculosis is diagnosed when it develops into infiltrative, fibrocavernous and septic forms.

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

Clinical manifestations of tuberculosis in HIV-infected patients:

• severe emaciation;
• 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
• decreased levels of hemoglobin and red blood cells in the blood
• possible enlargement of the liver and spleen
• Generalized lymphadenopathy is detected in 30% of patients.

With lymphadenopathy, the anterior cervical, axillary, intrathoracic, and less commonly inguinal lymph nodes become enlarged. They are dense in consistency, lumpy, and fused with adjacent tissues. In patients without immunodeficiency, the lymph nodes do not enlarge (with the exception of 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 lung tissue, lesions of the bronchial tree, resulting in cough and hemoptysis. Exhaustion and fever are typical symptoms for HIV-positive people.

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

1. Prolonged persistent increase in temperature to 39-40°C against the background of active anti-tuberculosis therapy;
2. Severe weight loss (almost 10 kg within 2-3 months);
3. Liquid, light, foamy sputum with a volume of up to 400 ml, easy to cough up;
4. Accelerated ESR (> 45 mm/h), leukocytosis up to 20 G/l;
5. X-ray in the lungs against the background of localization of the tuberculosis process in the upper part reveals scattered infiltrates, 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. Presence of oral candidiasis;
7. Uninformativeness of tuberculin tests;
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, widespread changes are determined with signs of enlargement of the hilar peritracheal and mediastinal lymph nodes.

If an extrapulmonary process is suspected, it is best to perform a computed tomography scan. HIV-infected patients are characterized by the development of tuberculous meningitis, which occurs especially rapidly in young people (18-24 years old).

The localization of the pulmonary process in HIV-infected patients is both typical and the 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 patients may be the reason for the low detection rate of tuberculosis and overdiagnosis of community-acquired pneumonia.

Features of the course of tuberculosis in HIV patients and the atypical localization of the process in the lungs may 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 tested for co-infection. Particular attention should be paid to patients with respiratory and intoxication symptoms

Examinations for suspected tuberculosis due to HIV infection

• Required:

1. collection of complaints and medical history;
2. three-time analysis of sputum (or other biological medium) by microscopy with Ziehl-Neelsen staining;
3. plain radiography of the chest organs;
4. three-time analysis of sputum or other biological medium by culture.

• Additional:

1. computed tomography of the chest;
2. fibrobronchoscopy with collection of rinsing water for microscopic and bacteriological examination;
3. biopsy of the lungs and enlarged lymph nodes;
4. fibroscopic examinations if damage to specific organs and systems is suspected (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:

I - II	Typical reaction. In case of primary infection or active tuberculosis process, the test is positive or hyperergic. If there is no infection, the test is negative.
III - IV	The reaction is atypical. The majority of patients (70%) have a negative test, despite the presence of infection and disease. A minority (30%) have a positive reaction to tuberculin.

Diagnosis of HIV infection in patients with tuberculosis

• collection of complaints and medical history;
• examination of peripheral lymph nodes;
• a detailed clinical blood test with determination of the leukocyte formula;
• determination of CD4 cell level and CD4/CD8 ratio;
• virological blood test;
• determination of the level of liver transaminases and bilirubin in the blood serum (an 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 using enzyme-linked immunosorbent assay.

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

• biopsy of enlarged peripheral lymph nodes with microscopic examination and culture of material for the presence of Koch bacteria;
• pleural biopsy with fluid culture for the presence of MBT in patients with exudative pleurisy;
• computed tomography of the chest and abdominal organs in persons with prolonged fever of unknown origin;
• five-fold urine culture 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 meningitis.

Treatment

Basic principles of treatment of co-infection:

• Treatment for active tuberculosis is more important from an epidemiological point of view than treatment for HIV infection, so treatment for co-infection begins with the prescription of anti-tuberculosis drugs
• treatment of tuberculosis in HIV infection is carried out according to the same regimens 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-tuberculosis drugs;
• after completion of the main course of antimycobacterial therapy (AMBT), preventive treatment is not used;
• Preventive treatment with Biseptol prevents death from Pneumocystis pneumonia.

Treatment of tuberculosis against the background of immunodeficiency

The main therapy is long-term continuous combination treatment with anti-tuberculosis drugs in the full daily dose in 1 dose. The standard course is carried out using 4-5 first-line anti-tuberculosis drugs - 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 MBT strains) and a maintenance phase, which lasts 4 months. Under no circumstances should you skip your daily dose of the drug.

Antituberculosis therapy for HIV infection should be selected taking into account the drug resistance of mycobacteria. In case of resistance, it is necessary to prescribe at least 2 main drugs active against the pathogen, and reserve drugs - ciprofloxacin (750 mg 2 times / day) or ofloxacin (400 mg 2 times / day).

Standard treatment regimens for patients with pulmonary tuberculosis:

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

Adverse reactions to antimycobacterial drugs

Adverse reactions to anti-tuberculosis drugs occur more frequently in HIV-positive individuals than in HIV-negative individuals. The risk of drug intolerance increases with increased immunosuppression, 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:

A drug	Adverse reactions	Correction methods
Isoniazid	Neurotoxic effects - headaches, dizziness, paresthesia, peripheral neuropathy. Hepatotoxic effect, allergic reactions.	Taking vitamin B6 at a dose of 20-40 mg/day, hepatoprotective therapy.
Rifampicin	Rarely: dyspeptic symptoms, toxic effects on the liver, acute renal failure, muscle and joint pain, hematopoietic disorders.	Hepatoprotective therapy. With the development of acute renal failure - complete withdrawal.
Ethambutol	Often: decreased visual acuity, headache, dizziness, dyspeptic disorders, increased viscosity of sputum, numbness and tingling in the fingertips.	Prescription of B vitamins, expectorants, proteolytic enzymes. If there is no effect, discontinue the drug.
Pyrazinamide	Often: dyspeptic symptoms (nausea, vomiting), redness of the skin. Rarely: hepatitis, joint pain, allergic reactions.	Prescription of antihistamines, hepatoprotectors. Reducing the dose of the drug. If there is no effect - complete cancellation.
Streptomycin	Common: tinnitus, hearing loss. Rare: toxic effect on the kidneys, dizziness, unsteady gait, increased blood pressure	Vitamin therapy (B1 and B6, pantothenic acid), calcium supplements, ATP. If there is no effect, discontinue the drug.

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. Antiretroviral therapy (ART) is used for this.

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

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

If the CD4 lymphocyte count is >200/mm3, then antiretroviral therapy should be postponed until the course of tuberculosis treatment is completed. In patients with extrapulmonary tuberculosis and/or CD4 cell 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, since patients die from various infectious complications of AIDS (usually Pneumocystis pneumonia).

During treatment, you should follow your doctor's instructions. Under no circumstances should you increase or decrease the dose of medications on your own. If you feel worse, tell your doctor immediately!

Drug interactions

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

Some ART drugs are contraindicated for use together with rifampicin (ritonavir). Combination therapy also reduces the concentration of some antiretroviral drugs in the blood (indinavir, lopinavir, saquinavir). This should be taken into account to increase the dose of the above drugs to achieve the desired effect. It is not recommended to prescribe ART during the intensive phase of anti-TB treatment.

Tuberculosis in HIV-infected patients is malignant and tends to generalize and progress due to severe immunodeficiency.

Identification of a patient with widespread and progressive tuberculosis serves as a signal for the need for targeted testing for HIV infection. At the same time, AIDS patients should be considered as potential tuberculosis patients.

The HIV epidemic has introduced and is constantly introducing radical changes in the epidemiology of tuberculosis. The main impact of HIV infection is expressed in the rate of progression of clinically evident tuberculosis in individuals previously infected with MVT.

Tuberculosis and HIV infection can be combined in three ways:

1. primary infection with tuberculosis in HIV-infected patients;
2. simultaneous infection with HIV infection and tuberculosis;
3. development of the tuberculosis process against the background of the development of immunodeficiency in HIV infection (AIDS).

People infected with both TB and HIV are at particularly high risk of developing the disease. Their annual probability of developing tuberculosis is 10%, while for the rest of the population this probability does not exceed 5% throughout their lives.

In countries with high HIV infection rates, more than 40% of tuberculosis patients are also HIV-infected. Due to the growing AIDS epidemic, epidemiological forecasts are very unfavorable.

Epidemiological analysis of data shows that the main route of transmission of HIV infection in Russia is parenteral, which occurs in the vast majority of cases through drug administration (96.8% of cases of established routes of transmission).

Among other high-risk groups (patients with sexually transmitted infections, people with homosexual orientation), the percentage of detected 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 at the end of the incubation period, at the time of primary manifestations and in the late stage of infection, when the concentration of the virus reaches its maximum, but the virus in the blood is poorly neutralized by antibodies. Humans are universally susceptible to HIV.

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 greatest epidemiological danger of HIV transmission is blood and seminal fluid.

Pathogenesis and pathomorphology. Factors that explain the pattern of predominant combination of tuberculosis and HIV infection are the peculiarities of the pathogenesis mechanisms of both diseases.

HIV infection significantly affects the state of immunoreactivity in tuberculosis, changing the relationships in the cellular immune system, disrupting the differentiation of macrophages and the formation of specific granulation tissue.

Accordingly, the more frequent development of tuberculosis in HIV-infected people can occur both due to a decrease in resistance to primary or repeated infection with MTB (exogenous infection), and as a result of reactivation of old residual post-tuberculosis changes, 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 typical tuberculous granulomas completely disappear; they lack the characteristic Pirogov-Langhans cells. At the same time, the number of epithelioid cells decreases significantly; 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 predominantly by cheesy necrosis with a large number of MBT with very weakly expressed exudative-proliferative processes. This is largely due to increased TNF-α expression. With the development of tuberculosis in an HIV-infected patient, a necrotic process develops in the lungs as a result of an increased release of this lymphokine.

The terminal period of AIDS in tuberculosis is characterized by the presence of typical necrosis. The affected tissues quickly undergo massive liquefaction and are literally “stuffed” with MVT. In the later stages of HIV infection, active tuberculosis 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 occurs, 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-indicative diseases (Pneumocystis pneumonia, toxoplasmosis, cytomegalovirus infection, Kaposi's sarcoma).

Clinical picture. The severity of the clinical manifestations of the tuberculosis process is greater, the smaller the number of CD4+ cells circulating in the peripheral blood. With an unfavorable prognosis for life in people with combined pathology, the immunogram shows a sharp decrease in the number of CD4+ lymphocytes, B-lymphocytes and natural killer cells, 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 during chemotherapy leads to death in 30% of cases.

The main clinical manifestations of tuberculosis against the background of HIV infection are asthenia, constant or intermittent fever, prolonged cough, significant loss of body weight, diarrhea, enlarged lymph nodes (mainly cervical and axillary, less often inguinal), dense in consistency, lumpy, difficult to move on palpation. The severity of tuberculosis symptoms in HIV-infected and AIDS patients largely depends on the degree of suppression of cellular immunity.

The disease most often occurs as an infiltrative or generalized process. The most typical complaints are weakness, cough, high fever and sweating. The patient is characterized by significant weight loss, the loss of body weight is 10-20 kg and always more than 10% of the initial one.

More pronounced clinical symptoms are observed in patients in whom tuberculosis arose against 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, can be the most typical and no different from the clinical and radiological picture in HIV-negative patients.

At this stage, patients are dominated by the usual manifestations of predominantly pulmonary tuberculosis. Upper lobe infiltrative and, less often, focal processes develop, in half of the cases with decay, so specific therapy is effective and tuberculosis is cured. As the number of CD4+ lymphocytes in the blood decreases (to 200 per 1 mm3 or less), along with pulmonary lesions (or instead of them), extrapulmonary localizations of tuberculosis are increasingly detected.

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

Clinical manifestations of tuberculosis are often atypical. When the lungs are affected, lobar infiltrates do not have a typical localization radiologically; the process is often 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 decreases, and the frequency of negative reactions is inversely proportional to the level of CD4+ lymphocytes.

Recently, reports have increasingly appeared about the predominance of extrapulmonary tuberculosis in HIV-infected individuals. In this case, it is possible to develop a specific process in the cervical, mesenteric, and less often tonsillar lymph nodes, as well as in the muscles of the chest and abdominal cavity and the brain with the development of specific abscesses and leaks. This often leads to the death of the patient, despite specific and surgical treatment.

In AIDS, deep damage to the immune system is detected when the content of CD4+ lymphocytes is less than 200-100 per 1 mm3, which indicates a decrease in T-cell immunity until it disappears. The most severe, acutely progressive and common processes develop, such as miliary tuberculosis and meningitis.

Tuberculous changes in the lungs of patients with AIDS 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, the upper parts of the lungs are significantly less often affected in them, and the cavities and atelectasis characteristic of tuberculosis are not so often formed.

Often, in patients with AIDS, instead of miliary rashes, radiographs of the lungs reveal diffuse confluent infiltrative changes that occur as caseous pneumonia. The significantly more frequent development of tuberculous mycobacteremia, which in patients with AIDS is complicated by septic shock with dysfunction of many organs, is considered very characteristic.

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

• studying the patient’s complaints and medical history;
• objective examination;
• blood and urine tests;
• chest radiography;
• three-fold microscopic examination of sputum and its inoculation on nutrient media;
• assessment of intradermal Mantoux reaction with 2 TE PPD-L;
• ELISA of anti-tuberculosis antibodies and tuberculosis antigens.

Difficulties in diagnosing tuberculosis arise mainly in the stage
secondary manifestations, including AIDS. The predominance during this period of disseminated and extrapulmonary forms with a sharp decrease in the number of cases of destruction of lung tissue significantly reduces the number of patients in whom MBT is detected in sputum by microscopy (using the Ziehl-Neelsen method) and by culture.

However, it must be taken into account that during this period of HIV infection and AIDS, mycobacteremia is determined in almost all patients and the detection of the pathogen in the peripheral blood is the most important diagnostic test.

Considering the high frequency of extrapulmonary lesions in patients with tuberculosis and AIDS, biopsies of lymph nodes, spleen, liver, bone marrow and other organs play an important role in diagnosis, where acid-fast mycobacteria can be detected in biopsies in more than 70% of patients.

During pathological examination of biopsy specimens, signs of decreased reactivity of the body are often determined, which is manifested in the extremely weak formation of granulomas with a predominance of necrosis, and in more than half of the cases, granulomas characteristic of tuberculosis are absent.

Study of tuberculin sensitivity using the Mantoux test with
2 TE PPD-L and ELISA determination of anti-tuberculosis antibodies and MBT antigens have limited diagnostic value due to immunosuppression and anergy to tuberculin in patients with tuberculosis and AIDS.

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

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 prescription of antiretroviral drugs is becoming a necessary element in the treatment of tuberculosis with advanced forms of infection.

• patients with tuberculosis with a CD4+ lymphocyte count of more than 350 per mm3 usually do not need antiretroviral therapy and are given only chemotherapy;
• for patients with tuberculosis with a CD4+ lymphocyte count from 350 to 200 per mm3, antiretroviral therapy is prescribed at the end of the intensive phase of chemotherapy, 2-3 months from the start of treatment;
• For patients with tuberculosis with a CD4+ lymphocyte count of less than 200 per mm3, antiretroviral therapy is prescribed simultaneously with chemotherapy.

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

HIV-infected patients with newly diagnosed pulmonary tuberculosis receive four main anti-tuberculosis drugs during the intensive phase of chemotherapy for 2-3 months: 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 advisable to use rifabutin, a synthetic analogue of rifampicin, in chemotherapy regimens.

A number of antiretroviral drugs (Zerit, Videx, Hivid) in combination with isoniazid mutually enhance neurotoxicity, therefore, in chemotherapy regimens it is better to use phenazide, a drug from the gink group that does not have neurotoxicity.

When drug resistance of MBT is detected, chemotherapy is adjusted and the duration of the intensive phase of treatment is extended. A combination of the main ones, to which the MBT has remained sensitive, and reserve drugs is possible, but the combination must consist of five drugs, of which at least two must be reserve.

The indication for the continuation phase of treatment is the cessation of bacterial excretion by sputum microscopy and positive clinical and 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 cessation of bacterial excretion and stabilization of the process in the lungs. Due to the risk of low effectiveness of the combination of reserve drugs, as well as relapses of tuberculosis caused by multi-resistant MBT strains, 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.

The disease caused by the immunodeficiency virus is one of the central threats to humanity. It hit every corner of the world. In countries where there are large numbers of HIV-infected patients, more than 40% suffer from tuberculosis. People diagnosed with HIV are at 10% greater risk of contracting tuberculosis than healthy people. How to live with a dual diagnosis?

Features of the course of diseases

HIV diseases and tuberculosis themselves are among the most dangerous diseases. In combination, they are even more aggressive. Immunodeficiency contributes to the rapid development of complications in the human body.

Tuberculosis in people diagnosed with HIV can develop in different ways:

1. A situation where both tuberculosis and HIV entered the body at the same time.
2. Tuberculosis begins to develop against the background of immunodeficiency.
3. The HIV virus originates in a body that is already infected with tuberculosis.

Patients who develop both diseases at the same time are at greatest risk. The disease passes very quickly and can lead to serious complications in a short period of time. HIV enters the human body through fluids contaminated with bacteria. You can become infected through blood, semen, or breast milk.

Despite the fact that tuberculosis and HIV infection occur in different ways, acquiring these diseases at the same time often occurs.

Tuberculosis is transmitted by airborne droplets. When the body suffers from immunodeficiency, tuberculosis begins to develop very quickly. The body cannot cope with the infection, since the person’s immunity is weakened.

Tuberculosis in HIV-infected people develops in several forms:

With HIV infection, the active phase of tuberculosis occurs very quickly. The reasons may be:

1. Old age or early childhood.
2. Poor nutrition.
3. Pregnancy.
4. Alcohol and drug abuse.

Symptoms of tuberculosis in HIV-infected people

The signs of tuberculosis in combination with HIV infection do not differ from the symptoms of infection in the standard form. With pulmonary tuberculosis and AIDS, symptoms depend both on the stage of the disease and on the sequence of infection. Thus, tuberculosis develops more aggressively if it enters a body already infected with HIV. In this form, the patient will experience the following symptoms:

Patients with HIV may develop not only tuberculosis of the lungs, but also of the lymph nodes; they increase in size, become dense and lumpy. In patients with a combination of HIV and tuberculosis, a broncho-nutritional fistula may form, and bleeding may also occur due to disturbances in the structure of the walls of large blood vessels.

Tuberculosis and HIV in children

In children, these diseases most often occur in the womb. They can be obtained either during pregnancy or during childbirth. Infection is possible if the mother became ill during pregnancy or was already infected. Early infection inside the womb is fatal in most cases. More than 90% of all cases of AIDS and tuberculosis in children occur in Africa.

Children born to women with AIDS are immediately taken from their mother after birth. This is done in order to avoid infection if it has not already occurred.

Tuberculosis and AIDS occur in children in the same form and with the same consequences as in adults. But it is harder for a small body to fight diseases. Children experience severe weight loss, which is very difficult to recover.

If the child has not had contact with the sick mother after birth, he is given a BCG vaccination, but if there was contact, the vaccination is prohibited. In addition, children are given a course of chemotherapy for preventive purposes.

If the child has been in contact with his mother, he is left in the hospital for observation by doctors, since in childhood the risk of infection is very high.

Diagnosis, treatment and prognosis

Diagnosis of tuberculosis developing against the background of HIV infection has its own characteristics associated with the stage of the AIDS disease. The earlier the diagnosis is made, the greater the chance of obtaining positive results. In the future, the disease can acquire a chronic form and begin to progress.

At the initial stage of HIV disease, the development of tuberculosis is practically no different from the development in people not infected with AIDS. Diagnosis consists of standard collection of clinical tests, chest x-ray, sputum culture and Mantoux test in children.

At the stage of advanced development of HIV infection, difficulties arise in making a diagnosis of tuberculosis. Difficulties arise because in the secondary form of AIDS, false-negative tests are possible.

Patients with HIV should be regularly examined for other diseases, in particular, undergo a chest x-ray. This will help to identify the disease at an early stage and take the necessary treatment measures in a timely manner. When tuberculosis and HIV are combined, the diseases are treated simultaneously.

Therapeutic treatment is prescribed to patients immediately after testing. It can take up to six months. But with an aggressive form of HIV, treatment of tuberculosis is delayed for a period of up to two years.

Treatment of HIV and tuberculosis involves taking anti-tuberculosis drugs and chemoprophylaxis. The whole process involves taking a large number of toxic drugs that can cause complications in other internal organs. To avoid exacerbation, you need to eat right and lead a healthy lifestyle. The room where the patient is located must be disinfected to avoid infecting other family members.

It is very important to prescribe timely treatment for tuberculosis and HIV in pregnant women. Because there is a high risk of transmitting infections to the fetus.

Many patients are interested in the most important question: how long do people live with HIV and tuberculosis. How long the patient can live depends on the stage of the disease and whether there are secondary lesions of the internal organs.

According to medical research, the life expectancy of such patients is half that of HIV-infected people. In the terminal stage of AIDS, therapeutic treatment does not bring results. In most cases, such patients die from complications arising from the disease.

The sooner the diagnosis is made, the longer the patient will live: this is why patients with HIV status need to undergo an x-ray examination annually.

The combination of tuberculosis and HIV infection is a dangerous phenomenon for the human body. In addition to timely and difficult treatment, the patient needs to completely change his lifestyle. Proper nutrition, regimen, taking vitamins, giving up bad habits - only in this case, subject to proper treatment, will it be possible to get a positive prognosis.