Original articleInfluence of HIV status on pathological changes in tuberculous pleuritis
Abstract
Setting: The AIDS epidemic has been associated with an increase in the incidence of tuberculosis, pulmonary or extrapulmonary.
Objective: To compare morphological changes in tuberculous pleurisy, and response to therapy in HIV-positive and-negative patients.
Design: 57 consecutive patients admitted between January and August 1991 with tuberculous pleurisy who were biopsy proven were studied. 36 were HIV-positive and 21 were HIV-negative.
Results: 3 types of morphological changes were observed: reactive, hyporeactive and non-reactive. Hypo- and non-reactive patterns were found in 14 of 36 HIV-positive patients but in only 2 of 21 HIV-negative patients (P < 0.02). In the HIV-positive group, 10 of the 14 with hypo- or non-reactive patterns had other HIV-related complications, compared to 6 of 22 with reactive patterns (P < 0.01). When HIV-positive patients' response to therapy was investigated, 2 of 5 patients with hypo- and non-reactive patterns improved compared to all 13 with reactive patterns (P < 0.05).
Conclusion: A hypo- or non-reactive tissue reaction in HIV-positive patients with tuberculous pleuritis seems to indicate a less favourable prognosis.
Résumé
Cadre: L'épidémie de SIDA a été associée à une augmentation de l'incidence de la tuberculose, qu'elle soit pulmonaire ou extra-pulmonaire.
Objet: Comparer les modifications morphologiques dans la pleurésie tuberculeuse et la réponse au traitement chez des patients VIH-positifs et chez des patients VIH-négatifs.
Schéma: Une série de 57 patients admis entre janvier et août 1991, atteints d'une pleurésie tuberculeuse prouvée par biopsie, a été étudiése. 36 étaient VIH-positifs et 21 VIH-négatifs. Résultats: Trois types de changement morphologique ont été observés: réactif, hyporéactif et non-réactif. Des aspects hyporéactifs et non-réactifs ont été trouvés chez 14 des 36 patients séropositifs et chez seulement 2 des 21 patients séronégatifs (P < 0.02). Dans le groupe séropositif 10 des 14 qui montraient un aspect hyporéactif ou non-réactif étaient atteints d'autres complications liées à l'infection VIH, comparé à 6 des 22 qui montraient un aspect réactif (P < 0.01). Lors de l'évaluation de la réponse au traitement de la part des malades VIH-positifs, 2 des 5 patients montrant un aspect hyporéactif ou non-réactif ont eu une amélioration de leur condition, comparé à l'ensemble des 13 qui montraient un aspect réactif (P < 0.05).
Conclusion: Une réaction tissulaire réduite ou absente chez des patients VIH-positifs atteints d'une pleurésie tuberculeuse semble indiquer un pronostic moins favorable.
Resumen
Marco de referencia: La epidemia de SIDA ha estado asociada a un aumento de la incidencia de la tuberculosis tanto pulmonar como extra-pulmonar.
Objetivo: Comparar las modificaciones morfológicas en la pleuresía tuberculosa y la respuesta al tratamiento en los pacientes VIH-positivos y -negativos.
Método: Se estudió una serie consecutiva de 57 pacientes hospitalizados entre enero y agosto de 1991, con pleuresía tuberculosa comprobada por biopsia. 36 eran VIH-positivos y 21 VIH-negativos.
Resultados: Se observó tres tipos de alteraciones morfológicas: reactivo, hipo-reactivo y no-reactivo. Los tipos hipo- y no-reactivo se encontraron en 14 de los 36 pacientes VIH-positivos y sólo en 2 de los 21 VIH-negativos (P < 0.02). En el grupo VIH-positivo, 10 de los 14 con tipos hipo- o no-reactivo presentaban otras complicaciones relacionadas con el VIH, comparado con 6 de los 22 del tipo reactivo (P < 0.01). Cuando se analizó la respuesta a la terapia de los pacientes VIH-positivos, se constató que 2 de 5 pacientes del tipo hipo y no-reactivo tuvieron una mejoría, comparado con la totalidad de los 13 del tipo reactivo (P < 0.05).
Conclusión: Una reacción tisular reducida o ausente en pacientes VIH-positivos con pleuresía tuberculosa, parece indicar un pronóstico menos favorable.
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Cited by (23)
Tuberculous pleural effusion and HIV infection at the pulmonary disease clinic in Abidjan, Ivory Coast
2007, Revue de Pneumologie CliniqueA partir d’une étude prospective conduite dans le service de Pneumo-Phtisiologie du Centre Hospitalier Universitaire de Treichville, à Abidjan, de début avril à fin décembre 1997 inclus, nous analysons les caractéristiques cliniques, radiographiques, biologiques et histo-pathologiques de 30 cas de tuberculose pleurale associée à l’infection à VIH.
L’âge moyen des patients était de 35 ans (extrêmes : 16-79 ans). L’examen cytologique du liquide pleural était à prédominance lymphocytaire chez tous les patients, et la recherche de bacilles tuberculeux dans le liquide pleural s’est avérée négative dans tous les cas. L’intradermo-réaction à 10 unités de tuberculine était négative chez 16 patients (53,3 %) et l’examen anatomo-pathologique des fragments de biopsie pleurale a identifié un follicule tuberculeux typique chez 19 malades (63,3 %) et un granulome inflammatoire non spécifique chez les 11 autres (36,7 %).
Clinical, radiographic, biological, histological and pathological data from thirty HIV-infected patients with tuberculous pleural effusion were prospectively collected at the pulmonary disease clinic at the University teaching hospital of Treichville in Abidjan from April to December 1999.
Patients mean age was 35 years, ranging from 16 to 79. The white cell count in the serous effusion pleural fluid was high with predominant lymphocytes. Microscopy examination of the aspirate did not show AFB. The Tuberculin Skin Test remained negative for 16 patients (53 %). Multiple pleural biopsies showed typical tuberculous follicles in 19 patients (63 %) and a non-typical inflammatory reactions in eleven patients (37 %).
Controversies in the treatment of extrapulmonary tuberculosis
2006, Archivos de BronconeumologiaLa tuberculosis (TB) puede afectar, por diseminación hematógena, linfática o contigüidad, a cualquier órgano o tejido del organismo. Sin embargo, la forma de presentación pulmonar es la más frecuente y la única epidemiológicamente importante. Esto ha motivado que las publicaciones sobre las diversas localizaciones de la TB extrapulmonar (TBE) hayan sido escasas, y casi siempre realizadas por especialistas de las diferentes presentaciones. Por tal motivo, en la mayoría de los grandes campos de estudio de la TBE se han aceptado recomendaciones similares a las efectuadas para la TB pulmonar, o se han seguido otras con escasa o nula evidencia; aspecto especialmente relevante en lo concerniente al tratamiento.
En el presente artículo se revisan importantes publicaciones que han dado lugar a las actuales recomendaciones sobre el tratamiento, detrás de la mayoría de las cuales resalta la falta de evidencia existente. En cualquier caso, se concluye que un régimen de 6 meses, similar al de la TB pulmonar, puede ser suficiente para tratar todas las formas de TBE, incluida la meníngea. Se discute, igualmente, el papel que los esteroides y la cirugía pueden tener en las diversas localizaciones de la TB, así como las modificaciones y/o consideraciones que deben tenerse en cuenta en los pacientes infectados por el virus de la inmunodeficiencia humana.
Tuberculosis (TB) can spread to any tissue or organ of the body by way of hematogenous or lymphatic dissemination or contiguity. However, pulmonary TB is the most common presentation and the only form of the disease of epidemiologic importance. Consequently, the literature on the various forms of extrapulmonary TB (EPTB) is scant, and most of the published authors are specialists in specific extrapulmonary forms. As a result, in most of the major areas of study of EPTB, recommendations similar to those for pulmonary TB or others based on little or no evidence have been accepted. This lack of evidence is of particular concern in the case of treatment guidelines.
The present article reviews important work that has given rise to current treatment guidelines. While most of these guidelines reveal the lack of evidence available on this subject, it can, nevertheless, be concluded that a 6-month treatment regimen similar to that used in patients with pulmonary TB may be sufficient to treat all forms of EPTB, including meningeal disease. The role of steroids and surgery in the treatment of TB affecting different sites is also discussed. Other topics dealt with are the considerations that should be taken into account and the treatment modifications necessary in patients infected with the human immunodeficiency virus.
Neuropathology of human immunodeficiency virus infection: A forensic autopsy study in Dar Es Salaam, Tanzania
2005, Forensic Science InternationalThe objective of this study was to examine the neuropathological changes in the brain of patients infected with human immunodeficiency virus (HIV) in the Tanzanian capital Dar Es Salaam, and investigate whether the prevalence of different forms of HIV-related neuropathology varies from other countries. The subjects were patients with risk factors for HIV infection in whom forensic autopsies were performed between 1997 and 1999. In Dar Es Salaam, forensic autopsy constitutes more than 90% of all autopsies, because hospital autopsy is limited due to socio-cultural and religious reasons.
HIV infection was identified in 52 of 143 patients selected from forensic autopsies. Neuropathological findings were observed in 31 of 52 HIV-infected patients; these include lymphocytic meningitis 19, bacterial meningitis 3, tuberculous brain abscess 3, cryptococcal meningitis 3, basal ganglia calcification 3, and toxoplasma encephalitis 1. HIV encephalitis, lymphoma, and cytomegalovirus encephalitis could not be found in this study. Whereas the findings should be interpreted cautiously because of possible autopsy bias and a low percentage of cases examined compared to the total number of HIV-infected patients in Tanzania, our observations provide information on the likely diagnostic possibilities to be considered in the evaluation and management of HIV-infected patients with neurological symptoms in Tanzania. In the face of decreased hospital autopsy, most studies have focused mainly on the end-stage HIV disease; forensic autopsy is a potential source of materials for studies on HIV disease spectrum at different stages.
To investigate the incidence, clinical features, and treatment of tuberculous pleurisy in AIDS patients.
We reviewed all cases of pleural tuberculosis in AIDS patients in South Carolina from 1988 through 1994. Clinical findings, test results, treatment, and outcome were analyzed.
Twenty-two (11%) of the 202 AIDS patients with tuberculosis had pleural involvement compared to 6% (169/2,817) pleural involvement in non-AIDS patients (p=0.01). Associated features of AIDS tuberculous pleurisy included substantial weight loss (7.65±1.35 kg) and lower lobe infiltrates (12/22; 55%). No difference in pleural fluid characteristics was found when comparing AIDS patients with a serum CD4 count ≥200/µL to patients with CD4 count <200/µL. Two (9%) of the 22 patients died of tuberculosis. Chest radiograph follow-up of 20 patients showed complete resolution in 7, improvement in 10, and no improvement in 3.
In South Carolina, pleural involvement is more common in AIDS patients than in non-AIDS patients with tuberculosis. Tuberculous pleurisy has several atypical features in AIDS patients such as substantial weight loss and lower lobe infiltrates. The outcome of treatment is good for most patients.
Clinical features of HIV seropositive and HIV seronegative patients with tuberculous lymphadenitis in Dar es Salaam
1995, Tubercle and Lung DiseaseSetting: The medical wards of a referral hospital in Dar es Salaam, Tanzania.
Objective: To investigate the impact of HIV infection on clinical features in tuberculous lymphadenitis.
Design: A prospective clinical study of HIV seropositive and HIV seronegative patients with lymphadenopathy.
Results: Of 128 patients with peripheral lymphadenopathy, 24 had no tuberculosis (TB) and in 10 patients TB was found only in other organs. The remaining 94 patients, of whom 76% were HIV seropositive, formed our study population. TB lymphadenitis was considered proven in 89 and probable in 5 patients. Disseminated TB (both TB adenitis and TB in other organs) was diagnosed more often in HIV seropositive than in HIV seronegative patients (52% versus 26%, P < 0.03). 59% of the 71 HIV-infected patients compared to only 4% of the 23 patients without HIV infection were over 30 years of age (P < 0.02). The following clinical features were significantly associated with HIV infection: dyspnoea, respiratory rate > 20/min, low motility score (bedridden), neurological abnormalities, hepatomegaly, splenomegaly, lymph node size < 2.5 cm, negative PPD skin test, lymphopenia (< 1000/cm3) and presence of pleural fluid.
Conclusion: Co-infection with HIV influences several clinical and laboratory features in patients with tuberculous lymphadenitis.
Cadre: Service médical d'un hôpital de référence à Dar es Salaam, en Tanzanie.
Objet: Evaluer l'impact de l'infection VIH sur les aspects cliniques d'une lymphadénite tuberculeuse.
Schéma: Etude clinique prospective de malades infectés ou non par le VIH et atteints d'une lymphadénite.
Résultats: Sur 128 malades atteints d'une lymphadénite périphérique, 24 n'étaient pas tuberculeux et chez 10 sujets une tuberculose a été observée dans d'autres organes. Les autres 94 malades, dont 76% étaient positifs pour le VIH, ont formé la population d'étude. Une lymphadénite tuberculeuse était considérée comme prouvée chez 89 et probable chez 5 malades. Une tuberculose disséminée (lymphadénite tuberculeuse et tuberculose dans d'autres organes) a été diagnostiquée plus souvent chez les malades séropositifs que chez les séronégatifs (52% par rapport à 26%, P < 0,03). 59% des 71 malades infectés par le VIH comparés à seulement 4% des 23 malades non-infectés étaient âgés de plus de 30 ans (P < 0,02). Les aspects cliniques suivants étaient associés à l'infection VIH: dyspnée, fréquence respiratoire > 20/min, taux de motilité peu élevé (grabataire), anomalies neurologiques, hépatomégalie, splénomégalie, taille des ganglions lymphatiques < 2,5 cm, test cutané PPD négatif, lymphopénie (< 1000/cm3) et présence de liquide pleural.
Conclusion: Une co-infection avec le VIH influence les aspects cliniques et paracliniques chez des patients atteints d'une lymphadénite tuberculeuse.
Marco de referencia: Las salas de medicina de un hospital de referencia en Dar es Salam, Tanzania.
Objetivo: Investigar el impacto de la infección VIH sobre las características clínicas de la linfadenitis tuberculosa.
Método: Estudio clínico prospectivo en pacientes VIH seropositivos y VIH seronegativos con linfoadenopatía.
Resultados: De un total de 128 pacientes con linfoadenopatía periférica, 24 no tenían tuberculosis (TB) y en 10 la tuberculosis fue detectada solamente en otros órganos. Los 94 pacientes restantes, de los cuales el 76% eran VIH seropositivos, constituyeron la población de nuestro estudio. En 89 pacientes la linfadenitis fue considerada como confirmada y en 5 como probable. La TB diseminada (tanto la adenitis TB como la TB de otros órganos) fue diagnosticada más frecuentemente en los pacientes VIH seropositivos que en los VIH seronegativos (52% versus 26%, P < 0,03). El 59% de los 71 pacientes infectados con VIH, comparado sólo con el 4% de de los 23 pacientes sin infección VIH tenían más de 30 años de edad (P < 0,02). Las siguientes características clínicas estaban significativamente asociadas a con la infección VIH: disnea, frecuencia respiratoria > 20/min, bajo grado de motilidad (postrado en cama), anormalidades neurológicas, hepatomegalia, esplenomegalia, tamaiño de los ganglios linfáticos < 2,5 cm, test PPD negativo, linfopenia (< 1000/cm3) y presencia de derrame pleural.
Conclusión: La coinfección con VIH tiene una influencia sobre varias características clínicas y de laboratorio en los pacientes con linfadenitis tuberculosa.
Direct comparison of the diagnostic yield of ultrasound-assisted Abrams and Tru-Cut needle biopsies for pleural tuberculosis
2010, ThoraxCitation Excerpt :Local disease prevalence may therefore dictate the choice of biopsy needle, and the Tru-Cut needle may still be the needle of choice in patients with suspected pleural malignancy. Kitinya et al found that the HIV status of a patient impacted on pleural biopsy results.37 Their data suggested that granulomas were less likely to be observed, whereas pleural tissue from HIV positive patients was more likely to be culture positive.
Tuberculous pleuritis remains the commonest cause of exudative effusions in areas with a high prevalence of tuberculosis and histological and/or microbiological confirmation on pleural tissue is the gold standard for its diagnosis. Uncertainty remains regarding the choice of closed pleural biopsy needles.
This prospective study compared ultrasound-assisted Abrams and Tru-Cut needle biopsies with regard to their diagnostic yield for pleural tuberculosis.
89 patients (54 men) of mean±SD age 38.7±16.7 years with pleural effusions and a clinical suspicion of tuberculosis were enrolled in the study. Transthoracic ultrasound was performed on all patients, who were then randomly assigned to undergo ≥4 Abrams needle biopsies followed by ≥4 Tru-Cut needle biopsies or vice versa. Medical thoracoscopy was performed on cases with non-diagnostic closed biopsies. Histological and/or microbiological proof of tuberculosis on any pleural specimen was considered the gold standard for pleural tuberculosis.
Pleural tuberculosis was diagnosed in 66 patients, alternative diagnoses were established in 20 patients and 3 remained undiagnosed. Pleural biopsy specimens obtained with Abrams needles contained pleural tissue in 81 patients (91.0%) and were diagnostic for tuberculosis in 54 patients (sensitivity 81.8%), whereas Tru-Cut needle biopsy specimens only contained pleural tissue in 70 patients (78.7%, p=0.015) and were diagnostic in 43 patients (sensitivity 65.2%, p=0.022).
Ultrasound-assisted pleural biopsies performed with an Abrams needle are more likely to contain pleura and have a significantly higher diagnostic sensitivity for pleural tuberculosis.