2.4 Clinical presentation in HIV-infected persons

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    Among HIV-infected persons, TB is the most common opportunistic infection and a leading cause of morbidity and mortality [1] Citation 1. Ford, N., et al., TB as a cause of hospitalization and in-hospital mortality among people living with HIV worldwide: a systematic review and meta-analysis. Journal of the International AIDS Society 2016, 19:20714.
    https://doi.org/10.7448/IAS.19.1.20714         . According to the WHO clinical staging system for HIV/AIDS, individuals with PTB are in clinical stage 3 and patients with EPTB in clinical stage 4 [2] Citation 2. World Health Organization. WHO Case definitions of HIV for Surveillance and Revised Clinical Staging and Immunological Classification of HIV-related disease in adults and children. Geneva: World Health Organization; 2007.
    https://apps.who.int/iris/handle/10665/43699         .

     

    In the early stages of HIV infection, when the immune system is functioning relatively normally, the clinical signs of TB are similar to those in non-infected individuals.

     

    As the immune system deteriorates in later stages of the disease, smear-negative PTB, disseminated TB and EPTB become more common. These cases are more difficult to diagnose, and have a higher fatality rate than smear-positive PTB cases.
    Patients may have difficulty expectorating, so more advanced sputum collection techniques may be necessary (Chapter 3 and Appendix 3). 

     

    The algorithm presented in Chapter 5 use clinical criteria combined with laboratory and other investigations to help diagnose TB in HIV-infected persons.

     

    Table 2.2 provides a differential diagnosis of PTB in HIV-infected persons.

     

    Table 2.2 – Differential diagnosis for PTB 

     

    Diseases

    Notes

    Other pneumonia
    (bacterial, viral, atypical)
    • Bacterial pneumonia (most often S. pneumoniae, H. influenzae) is common at all stages of HIV infection.
    • Atypical pneumonia (M. pneumoniae, C. pneumoniae) and viral pneumonia are possible at any CD4 count, except in the case of cytomegalovirus, which occurs at CD4 < 50.

    Pneumocystosis
    (Pneumocystis jirovecii pneumonia or PCP or PJP)
    • PCP has many characteristics in common with PTB (insidious onset, persistent cough, fever) but tends to occur in the advanced stages of HIV infection (CD4 < 200).
    • PCP is unlikely in patients taking co-trimoxazole prophylaxis. 
    • It imparts a greater degree of dyspnoea, rarely produces effusions, and is not usually accompanied by haemoptysis.

    Pulmonary Kaposi's sarcoma
    (KS)
    • KS can resemble PTB, with slow onset of cough, fever, haemoptysis, night sweats and weight loss. It is a disease of advanced stage HIV, and in most cases, is preceded or accompanied by lesions involving the skin and mucous membranes.

    Less common diseases
    • Pulmonary cryptococcosis, histoplasmosis and other fungal infections.
    • Pulmonary nocardiosis.

     

    The most common EPTB in HIV-infected persons are miliary TB, TB meningitis and diffuse lymphadenopathy in children, and lymph node TB, pleural effusion, pericarditis, TB meningitis and miliary TB in adults.

     

    Immune reconstitution inflammatory syndrome (IRIS) is a clinical presentation of TB in patients starting antiretroviral therapy. For clinical presentation and management of IRIS, see Chapter 12.

     

    Referencias
    • 1.Ford, N., et al., TB as a cause of hospitalization and in-hospital mortality among people living with HIV worldwide: a systematic review and meta-analysis. Journal of the International AIDS Society 2016, 19:20714.
      https://doi.org/10.7448/IAS.19.1.20714
    • 2.World Health Organization. WHO Case definitions of HIV for Surveillance and Revised Clinical Staging and Immunological Classification of HIV-related disease in adults and children. Geneva: World Health Organization; 2007.
      https://apps.who.int/iris/handle/10665/43699
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