Health MED – V olume 8 Number 2 2014 [601097]

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Abstract
Background: Tuberculosis (TB ) is one of the
most common opportunistic infections in patients
with HIV/AIDS. The aim of the study was to assess the epidemiological and clinical features of tubercu-losis in HIV-infected patients using two algorithms.
Materials and Methods: HIV infection was
confirmed by Western blot. CD4 counts were de-termined by flow cytometry. First algorithm identi-fied TB patients using symptoms, chest X-ray and tuberculosis skin test. Second algorithm comprised sputum cultures associated with direct microscopy.
Results: A total of 102 HIV-infected patients
were identified. Cough was present in 18 while fe-ver, 20 patients were having pulmonary infiltrates, 6 adenopathy and 3 infiltrates and adenopathy. Af-ter applying both algorithms, 5 HIV-infected pati-ents (4.90%) with definite TB were found.
Conclusion: A diagnostic management strategy
using two simple clinical decision rules is effective in the evaluation and management of HIV-infected patients with clinically suspected tuberculosis.
Key words: Tuberculosis, HIV-infected pati-
ents, tuberculin skin test, CD4.
Introduction
The Human Immunodeficiency Virus (HIV) is
causing the most destructive epidemic of recent
times, having been responsible for the deaths of
more than 25 million people since it was first re-
cognized in 1981 (1). HIV infection remains of major public health importance in Europe, with an estimated 802,000 people living with HIV in EU/
EEA countries and more than 30 percent of HIV-
infected people are unaware of their infection (2).
In Romania, latest data reported that 16,000
people were living with HIV/AIDS in 2009. Ro-
mania is the only country in Central and Eastern Europe providing universal access to treatment
and care for this disease (3).
Dual infection with Mycobacterium tubercu-
losis and HIV affects nearly 11 million people
worldwide (4). Co-infection of HIV-infected pa-
tients with tuberculosis together with problems
in health care systems and infrastructure, have
an important impact on treatment success. In the
absence of anti-retroviral therapy, HIV-infected patients with latent tuberculosis infection have 5–10% annual risk of TB in contrast to 10% du-ring the life-time in HIV negative patients (5, 6).
Pulmonary tuberculosis (TB) is conventionally
diagnosed by a combination of symptoms, chest X-ray (CXR), direct staining of Mycobacteri-um tuberculosis in sputum, sputum culture or by nucleic acid amplification techniques, where these are available (7).
Furthermore, the World Health Organizati-
on (WHO) recommends cough as the trigger for tuberculosis screening in HIV-infected patients, with acid-fast bacillus (AFB) smear as the initial diagnostic test (8). The most commonly used and reliable specimen for bacteriological examinati-on is sputum for the diagnosis of pulmonary TB, but when the patient cannot expectorate sputum, several methods, such as laryngeal swab, sputum induction, gastric aspiration, and bronchoalveolar lavage, can be used to obtain specimens for smear or culture examination for acid-fast bacilli (9).
A great challenge in the diagnostic work-up of
HIV-infected patients with clinically suspected TB is to accurately and quickly diagnose the pre-sence of TB, for an early treatment. Because of the very frequent association of tuberculosis and HIV , it has become necessary to look for tuberculosis in
HIV-infected patients and vice versa (10).
The aim of this study was to assess the epide-
miological and clinical features of tuberculosis in Trends in epidemiology of tuberculosis in HIV-
infected patients
Iosif Marincu1, Simona Claudia Cambrea2, Adelina Mavrea3, Mirela Cleopatra Tomescu3
1 Department of Infectious Diseases, “Victor Babes” University of Medicine and Pharmacy Timisoara, Romania,
2 Department of Infectious Diseases, “Ovidius” Faculty of Medicine, University Constanta, Romania,
3 Department of Internal Medicine, “Victor Babes” University of Medicine and Pharmacy Timisoara, Romania.

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HIV-infected patients in a 6 months period in 2
infectious diseases centres from Romania and to propose two simple algorithms for detection of TB in HIV-infected patients.
Material and methods
The study included all HIV-infected patients,
aged at least 15 years, which received antiretro-
viral therapy, from the evidence of Infectious Disease Clinics of Timisoara and Constanta. We excluded from the study HIV-infected patients with serious opportunistic infections, sepsis, me-ningoencephalitis, and coma, cardiac, respiratory, hepatic, renal or circulatory failure, neoplasm or hematologic malignancies. Data concerning de-mographic (age, sex, location) and clinical cha-racteristics (symptoms) were recorded.
Diagnosis of HIV statusIn all patients, HIV infection was confirmed by
Western blot and HIV-1 env DNA gene detection by PCR (11). The immune status was evaluated, and staging of HIV/AIDS was done according to international criteria, developed by CDC Atlanta, in 1993. CD4 cell counts were also evaluated by flow cytometry in all subjects.
Diagnosis of TBAll patients were subjected to chest radiograph
and sputum smear AFB examination of three sam-ples. Mantoux test using 5 TU of purified protein derivative (PPD) was done and transverse diame-ter of induration was noted in mm in all patients.
Than, first screening algorithm was applied
to identify TB suspects using a short, structured screening questionnaire (symptoms), chest X-ray (CXR) and IDR to tuberculin (TST) (Figure 1). X-ray images were scored as showing no abnormali-ties or abnormalities not suggestive of TB (nega-
tive) or abnormalities suggestive of TB (positive).
Then, second screening algorithm that compri-
sed bacteriological investigation was applied to all
HIV-infected patients with positive symptoms and positive CXR. The bacteriological examination
was based on the detection of BK by sputum cultu-
res (spontaneous or induced sputum and broncho-
alveolar lavage), associated with direct microscopy of AFB stained sputum smear (Figure 2).
Figure 1. First screening algorithm to detect TB in HIV-infected patients
Figure 2. Second screening algorithm to detect TB in HIV-infected patients
Statistical analysisData were analysed using statistical computer
software, MedCalc version 12.1.4.0. The descrip-tive data were given as means ± standard devia-tion (SD). The differences were considered to be statistically significant when the p value obtained
is less than 0.05.
Ethical approvalThe study was approved by the research ethics
committees of the “Victor Babes” University of Medicine and Pharmacy Timisoara, Romania and “Ovidius” Faculty of Medicine and University Constanta, Romania and written informed consent was obtained from all participants.

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Results
The study included 102 HIV-infected patients
(M = 52, W = 50, mean age = 27.74 ± 12.45 ye-
ars with a range of 19-65 years), retrospectively
recruited from two centers for infectious diseases,
Timisoara and Constanta from Romania.
The age distribution revealed that the highest
incidence of TB suspects in HIVinfected patients
was found in the groups of age under 20 years
(45%). Most patients (n=65) included in the study
were from urban areas, and the rest (n=37) were
from rural areas (Table 1).
Table 1. Age, sex and location distribution of HIV-
infected patients
Age Number Percentage (%)
<20 46 45
20-34 31 30.4
35-44 5 5
45-54 14 13.8
>55 6 5.8
Total 102 100
Sex
Male 52 51
Female 50 49
Total 102 100
Location
Rural 37 36.2
Urban 65 63.8
Total 102 100
Cough was the most common symptom present
in 18 patients (17%), followed by fever, weight
loss and sweating present in 5 (5%), 5 (5%) and 3 (3%) patients, respectively.
Following the number of symptoms per pati-
ent, we noted that most patients (16) had just a symptom, 2 patients were registered with two symptoms, 1 patient experienced three symptoms, and 2 patients reported four symptoms.Radiological examination is known as a routi-
ne procedure used in identifying patients with TB. In this study, 20 patients (20%) were having pul-monary infiltrates, 6 (6%) adenopathy, and 3 (3%) infiltrates and adenopathy. There is no patient with caseous or ulcerative lesions (cavitations).
Using the algorithm proposed, 51 patients were
categorised as “non TB”, 12 patients with “TB probably likely” were monitored at the Prevention Centre for TB, and 39 patients with “TB likely” continued bacteriological investigation. Bacterio-
logical confirmation was indicated in all potential
positive TB patients. Considering the results of
bacteriological investigation, patients with posi-tive BK results on cultures or microscopy were diagnosed as “definite TB cases” and referred to
anti-TB treatment. “Non-TB cases” were consi-
dered those with negative BK results on cultures
of secretions obtained by bronchoalveolar lavage, associated with negative BK microscopy.
By all HIV-infected patients studied, 2 pati-
ents were found with a positive sputum culture of spontaneous BK and 3 patients had positive BK culture from bronchoalveolar lavage. All 5 HIV-infected patients (4.90%) were considered definite cases with TB.
An association between symptoms and the pre-
sence of radiological changes was observed in 5 (5%) patients with severe immunosuppression, in 5 (5%) with moderate immunosuppression, and in 1 (1%) patient with balanced immune status. Alt-hough all 15 patients with a history of TB were under antiretroviral therapy, 2 had severe immu-nosuppression (Li CD4 < 200/mm
3), 7 had mode-
rate immunosuppression (CD4 between 200-499/mm
3 Li), and 6 were in balanced immune status
(Li CD4 > 500/mm3) (Table 2).
Table 2. Association between symptoms, chest X-ray and values of Li CD4
Clinical
CategoriesLi CD4
levelsPacient
number
n (%)Patients
with
symptomsPatients with
positive
CXRPatients with
symptoms and
positive CXRp value
C3 < 200/mm334 (33%) 11 (11%) 5 (5%) 5 (5%) NS
C2 200-499/mm315 (15%) 8 (8%) 9 (9%) 5 (5%) NS
C1 > 500/mm330 (29%) 2 (2%) 10 (10%) 1 (1%) NS
CXR: Chest X-ray NS: Nonsignificant (p>0.05)

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Discussion
In 1989, Romania experienced a unique, major
nosocomial HIV epidemic in which several tho-
usand institutionalised children contracted HIV through blood transfusions. Since then, the rates of diagnosed HIV cases doubled between 2000
and 2009 in countries like Bulgaria, Hungary,
Lithuania, Slovakia and Slovenia, but in Romania,
new HIV cases decreased by more than 20%. The
proportion of eligible patients that received antire-
troviral therapy in Romania at the end of 2010 was
about 60-79 % (12, 13).
HIV promotes the progression of latent TB
infection to disease, and TB accelerates the pro-gression of the HIV disease. Delayed diagnosis
and improper management of people with TB and
HIV co-infection may lead to spread of TB wit-
hin the community, contribute to the development of drug resistant TB, and lead to poorer health outcomes for HIV-infected patients. Tuberculosis co-infection is associated with a doubling of the mortality rate in HIV-infected people. The most significant predictor of survival for HIV-infected patients with coexistent TB is the degree of immu-nodeficiency (14).
In our study, distribution by age showed the
predominance of people less than 25 years (45%), confirming that TB coinfection in HIV-infected patients is more common in sexually active age group. Given the risk of TB and the unknown risk of opportunistic infections in HIV-infected pati-ents, monitorisation should include preliminary detection of TB in this population.
Tuberculosis in HIV-infected patients may
have unusual clinical features and can cause di-agnostic difficulties. Signs and symptoms (fever, weight loss, and fatigue) can be caused by tuber –
culosis and other atypical mycobacterium infecti-
ons (lymphoma, AIDS Wasting syndrome, CMV
infection, etc.). This was confirmed by the results
we obtained in the study group where only 21 pa-tients had symptoms of TB diagnosis oriented. Therefore, the authors included in the algorithm
for detecting TB in these patients, in addition to
symptoms and radiological changes, the IDR to
tuberculin. Similar with other studies, cough was the most common symptom, followed by fever, weight loss and sweating (15, 16).In people with HIV infection, the diagnosis of
TB may be problematic due to confusion with other
opportunistic infections and other HIV related di-
seases. Tuberculosis may present as a disseminated disease or with atypical clinical (or radiological) presentations, including enlarged hilar and/or me-
diastinal lymph nodes, pleural effusion, and lower
lobe infiltrates; this is particularly the case in those
with severe immunodeficiency (17-19).
Typical and cavitary lesions are usually obser –
ved in patients with higher CD4 counts, and more atypical patterns are observed in patients with lower CD4 counts. In patients with symptoms and signs of TB, a negative chest radiograph result does not exclude TB (20).
Inour study, 20 patients (20%) were having
pulmonary infiltrates, 6 (6%) adenopathy, and 3 (3%) infiltrates and adenopathy. There is no pa-tient with caseous or ulcerative lesions (cavitati-ons). In The Terry Beirn Community Programs for Clinical Research on AIDS, pulmonary infiltrates were seen among 67%, adenopathy in 7%, pul-monary nodule in 20%, cavity in 20% and pleural effusion in 10% (21).
CD4 count measure the degree of immuno-
suppression in HIV-infected patients (22). Tuber –
culosis, unlike other HIV-associated opportunistic infections may occur at relatively high levels of CD4, although its frequency markedly increases in patients with more severe immunosuppression (23). Clinical symptoms indicative of tuberculo-sis were more frequent among patients with CD4 <200/mm3, while radiological changes occurred at a lower frequency among persons with low CD4 Li, but the differences were not statistically significant. In our study, stage C of HIV/AIDS was found in 81(79%) of HIV-infected patients. This requires the establishment of rigorous monitoring measures associated with early detection as TB in these patients. The number of patients with mar –
ked immunosuppression (35%) was close to the number of those with controlled immune status (29%) due to antiretroviral therapy administered. Moreover, this feature could explain the selected group and number of patients (n=5) identified as definite pulmonary TB. These HIVinfected pati-ents could be clinically and biologically supervi-sed in two traditional university clinics. The cli-nical experience in this consistent pathology is

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relatively new and difficult for some hospitals in
other geographic areas, where the application of this algorithm could lead to other results.
Monitored cases (n=12), respectively negative
symptoms and negative CXR, but positive TST will be strictly controlled by both TB Prevention Centres from Timisoara and Constanta, and the In-fectious Diseases Clinic where they are in record time to capture the appearance of clinical or radi-ological changes. Possible TB cases (n=49) resul-
ting from the combination of three basic elements
– positive symptoms, or positive chest X-ray or
positive TST, will also be closely monitored in pa-
rallel clinics by specialists in infectious diseases
and TB for detection of subclinical forms, latent
bacteriological confirmed TB, but will be treated
according to known rules.
Using proposed algorithms, 49 of the 102 HIV/
AIDS patients were identified with suspected TB, which would not have been possible through a rou-tine examination. It shows that sometimes a single
factor represents the main element of suspicion of
TB. A special attention should be given to HIV-in-
fected patients with a history of pulmonary or extra-
pulmonary TB (15 patients in the study). In these patients, due to immunosuppression, the risk of re-
infection or relapse is high and has to be early iden-
tified, properly monitored, and effectively treated.
In order to avoid false-negative results that
may occur through direct bacterioscopy or sputum cultures or need for cooperation and compliance
from patients, but also seriously and conscien-
tiously from health professionals involved in the
diagnostic laborious process. We suggest, whe-
re possible, to advise and prepare the patient by health professionals who work with the office of psychological counseling in the hospital.
Conclusions
A diagnostic management strategy using two
simple clinical decision rules is effective in the
evaluation and management of HIV-infected pati-ents with clinically suspected tuberculosis.
Study limitation
Although sputum cultures remain the gold
standard in diagnosing TB, we met difficulties with patients compliance and collaboration. Some
patients refused bronchoscopy and preferred to give spontaneous sputum that was saliva leading to erroneous results and requiring a fresh sam-ple from induced sputum or secretions obtained by laryngeal-tracheal lavage. Although they had agreed to participate in the study, the patients had difficulties in accepting all investigations, which indicates the need for their psychologically coun-selling during the study.
Acknowledgments/Funding
We thank leadership, specialists, and staff from
the Centre for Health Policy and Services Buc-
harest (CPSS) that contributed to this Grant with funding from the Global Fund against HIV/AIDS, Tuberculosis, and Malaria through Romanian Angel Appeal. We thank all laboratory staff and Infectious Diseases and TB clinics which contri-buted to complete this project conducted in par –
tnership between specialist clinics in Timisoara and Constanta from Romania.
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Corresponding Author
Iosif Marincu,
Department of Infectious Diseases, Pneumology and
Parasitology, “Victor Babes” University of Medicine and Pharmacy, Timisoara,
Romania,
E-mail: imarincu@umft.ro