Tuberculosis and acquired immunodeficiency syndrome: A historical perspective on recent developments

doi:10.1016/0002-9343(94)90171-6

The American Journal of Medicine

Volume 96, Issue 5, May 1994, Pages 439-450

https://doi.org/10.1016/0002-9343(94)90171-6 Get rights and content

Abstract

The incidence of tuberculosis has increased in recent years, at least in part as a result of the ongoing worldwide epidemic of acquired immunodeficiency syndrome (AIDS). In addition, the occurrence of outbreaks caused by multidrug-resistant Mycobacterium tuberculosis organisms has greatly heightened concern. In retrospect, a number of seminal studies that have appeared during the past decade have helped to define changing concepts concerning the epidemiology, pathogenesis, approaches to preventive care, diagnosis, and treatment of tuberculosis in HIV-infected persons. Such reports have shown that the variable clinical manifestations of tuberculosis in patients with AIDS are greatly influenced by the degree of HIV-induced immunosuppression. Explosive outbreaks of tuberculosis occurring in closed environments have emphasized that patients with AIDS and pulmonary tuberculosis may be highly contagious, especially when diagnosis and implementation of appropriate infection control measures are delayed. The extent to which homelessness and illicit drug use complicate management of tuberculosis have been examined, and the high risk of persons who are both tuberculin-positive and HIV-positive ultimately developing active tuberculosis, unless chemoprophylaxis is completed, has been clearly shown. The utility of sputum smears, bronchoscopy, and newer technologies such as polymerase chain reaction for diagnosis has been examined. The risk of relapse appears to be low when patients with AIDS with drug-sensitive tuberculosis complete appropriate multiple-drug therapy. Recent reports have addressed important hospital infection control, tuberculin testing, and chemoprophylaxis issues. This paper describes this evolution of understanding, focusing on reports that we believe have been conceptually important.

References (88)

HL Rieder et al.
Tuberculosis and the acquired immunodeficiency syndrome
Chest
(1986)
JM Fitzgerald et al.
The impact of human immunodeficiency virus infection on tuberculosis and its control
Chest
(1991)
E Louie et al.
Tuberculosis in non-Haitian patients with the acquired immunodeficiency syndrome
Chest
(1986)
S Handwerger et al.
Tuberculosis and the acquired immunodeficiency syndrome at a New York City hospital: 1978–1985
Chest
(1987)
JR Pierce et al.
Transmission of tuberculosis to hospital workers by a patient with AIDS
Chest
(1992)
MP Dubé et al.
Tuberculous meningitis in patients with and without human immunodeficiency virus infection
Am J Med.
(1992)
NC Klein et al.
Use of mycobacterial smears in the diagnosis of pulmonary tuberculosis in AIDS/ARC patients
Chest
(1989)
F Kramer et al.
Delayed diagnosis of tuberculosis in patients with human immunodeficiency virus infection
Am J Med.
(1990)
SH Salzman et al.
The role of bronchoscopy in the diagnosis of pulmonary tuberculosis in patients at risk for HIV infection
Chest
(1992)
A Brisson-Nöel et al.
Rapid diagnosis of tuberculosis by amplification of mycobacterial DNA in clinical samples
Lancet
(1989)

N Manjunath et al.

Evaluation of a polymerase chain reaction for the diagnosis of tuberculosis

Tubercle

(1991)

CM Nolan

Human immunodeficiency syndrome-associated tuberculosis: a review with an emphasis on infection control issues

Am J Infect Control

(1992)

P Sundre et al.

Tuberculosis: a global overview of the situation today

Bull WHO

(1992)

Centers for Disease Control

HIV prevalence estimates and AIDS case projections for the United States: report based upon a workshop

MMWR

(1990)

JF Murray

Cursed duet: HIV infection and tuberculosis

Respiration

(1990)

PF Barnes et al.

Tuberculosis in patients with human immunodeficiency virus infection

NEJM

(1991)

JA Jereb et al.

Tuberculosis morbidity in the United States: final data, 1990

MMWR

(1991)

BR Bloom et al.

Tuberculosis: commentary on a reemergent killer

Science

(1992)

L Slutsker et al.

Epidemiology of extra-pulmonary tuberculosis among persons with AIDS in the United States

Clin Infect Dis.

(1993)

HLO Rieder et al.

Tuberculosis in the United States

JAMA

(1989)

PA Selwyn

Tuberculosis in the AIDS era: a new threat from an old disease

NY State J Med.

(1991)

PM Small et al.

Treatment of tuberculosis in patients with advanced human immunodeficiency virus infection

NEJM

(1991)

JM Llibre et al.

Risk stratification for dissemination of tuberculosis in HIV-infected patients

Q J Med.

(1992)

J Vieira et al.

Acquired immune deficiency in Haitians: opportunistic infections in previously healthy Haitian immigrants

NEJM

(1983)

AE Pitchenik et al.

Tuberuculosis, atypical mycobacteriosis, and the acquired immunodeficiency syndrome among Haitian and non-Haitian patients in South Florida

Ann Intern Med.

(1984)

AE Pitchenik et al.

The radiographic appearance of tuberculosis in patients with the acquired immune deficiency syndrome (AIDS) and pre-AIDS

Am Rev Respir Dis.

(1985)

Centers for Disease Control

Revision of the CDC surveillance case definitions for acquired immunodeficiency syndrome

MMWR

(1987)

Centers for Disease Control and Prevention

1993 revised certification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults

MMWR

(1992)

PA Selwyn et al.

A prospective study of the risk of tuberculosis among intravenous drug users with human immunodeficiency virus infection

NEJM

(1989)

P Theuer et al.

Human immunodeficiency virus infection in tuberculosis patients

J Infect Dis.

(1990)

IM Onorato et al.

Field Services Branch

G Di Perri et al.

Nosocomial epidemic of active tuberculosis among HIV-infected patients

Lancet

(1989)

CL Daley et al.

An outbreak of tuberculosis with accelerated progression among persons infected with the human immunodeficiency virus

NEJM

(1992)

G Di Perri et al.

Transmission of HIV-associated tuberculosis to healthcare workers

Infect Control Hosp Epidemiol.

(1993)

KG Castro et al.

Mycobacterium tuberculosis transmission in healthcare settings: is it influenced by coinfection with human immunodeficiency virus?

Infect Control Hosp Epidemiol.

(1993)

ML Pearson et al.

Nosocomial transmission of multidrug-resistant Mycobacterium tuberculosis: a risk to patients and health care workers

Ann Intern Med.

(1992)

Centers for Disease Control

Nosocomial transmission of multidrug-resistant tuberculosis among HIV-infected persons — Florida and New York, 1988–1991

MMWR

(1991)

MA Fischl et al.

Clinical presentation and outcome of patients with HIV infection and tuberculosis caused by multipledrug-resistant bacilli

Ann Intern Med.

(1992)

RM Ikeda et al.

Nosocomial transmission of drug resistant tuberculosis, New York

Centers for Disease Control

Transmission of multidrug-resistant tuberculosis from an HIV-positive client in a residential substance-abuse treatment facility—Michigan

MMWR

(1991)

E Nardell et al.

Exogenous reinfection with tuberculosis in a shelter for the homeless

NEJM

(1986)

R Torres et al.

Human immunodeficiency virus infection among homeless men in a New York City shelter

Arch Intern Med.

(1990)

A Pablos-Mendez et al.

Drug resistant tuberculosis among the homeless in New York City

NY State J Med.

(1990)

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Current concepts in the management of tuberculosis
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Citation Excerpt :
Diagnosis and response to therapy may be assessed through bronchoscopy.26 Extrapulmonary TB accounts for roughly 15% of TB cases among immunocompetent hosts27 and for 50% to70% of cases that occur in the context of coinfection with HIV.28–30 In low-incidence countries, immigrants from endemic countries are much more likely to present with extrapulmonary TB.31–33
Tuberculosis (TB) poses a serious threat to public health throughout the world but disproportionately afflicts low-income nations. Persons in close contact with a patient with active pulmonary TB and those from endemic regions of the world are at highest risk of primary infection, whereas patients with compromised immune systems are at highest risk of reactivation of latent TB infection (LTBI). Tuberculosis can affect any organ system. Clinical manifestations vary accordingly but often include fever, night sweats, and weight loss. Positive results on either a tuberculin skin test or an interferon-γ release assay in the absence of active TB establish a diagnosis of LTBI. A combination of epidemiological, clinical, radiographic, microbiological, and histopathologic features is used to establish the diagnosis of active TB. Patients with suspected active pulmonary TB should submit 3 sputum specimens for acid-fast bacilli smears and culture, with nucleic acid amplification testing performed on at least 1 specimen. For patients with LTBI, treatment with isoniazid for 9 months is preferred. Patients with active TB should be treated with multiple agents to achieve bacterial clearance, to reduce the risk of transmission, and to prevent the emergence of drug resistance. Directly observed therapy is recommended for the treatment of active TB. Health care professionals should collaborate, when possible, with local and state public health departments to care for patients with TB. Patients with drug-resistant TB or coinfection with human immunodeficiency virus should be treated in collaboration with TB specialists. Public health measures to prevent the spread of TB include appropriate respiratory isolation of patients with active pulmonary TB, contact investigation, and reduction of the LTBI burden.
Association of TNF-α-238G/A and 308 G/A gene polymorphisms with pulmonary tuberculosis among patients with coal worker's pneumoconiosis
2010, Biomedical and Environmental Sciences
Tumor necrosis factor-α (TNF-α) may play an important role in host's immune response to mycobacterium tuberculosis (M. tuberculosis) infection. This study was to investigate the association of TNF-α gene polymorphism with pulmonary tuberculosis (TB) among patients with coal worker's pneumoconiosis (CWP).
A case-control study was conducted in 113 patients with confirmed CWP complicated with pulmonary TB and 113 non-TB controls with CWP. They were matched in gender, age, job, and stage of pneumoconiosis. All participants were interviewed with questionnaires and their blood specimens were collected for genetic determination with informed consent. The TNF-α gene polymorphism was determined with polymerase chain reaction of restriction fragment length polymorphism (PCR-RFLP). Frequency of genotypes was assessed for Hardy-Weinberg equilibrium by chi-square test or Fisher's exact probability. Factors influencing the association of individual susceptibility with pulmonary TB were evaluated with logistic regression analysis. Gene-environment interaction was evaluated by a multiplicative model with combined OR. All data were analyzed using SAS version 8.2 software.
No significant difference in frequency of the TNF-α-308 genotype was found between CWP complicated with pulmonary TB and non-TB controls (χ²=5.44, P=0.07). But difference in frequency of the TNF-α-308 A allele was identified between them (χ²=5.14, P=0.02). No significant difference in frequencies of the TNF-α-238 genotype and allele (P=0.23 and P=0.09, respectively) was found between cases and controls either, with combined (GG and AA) OR of 3.96 (95% confidence interval of 1.30∼12.09) at the -308 locus of the TNF-α gene, as compared to combination of the TNF-α-238 GG and TNF-α-308 GG genotypes. Multivariate-adjusted odds ratio of the TNF-α-238 GG and TNF-α-308 GA genotypes was 1.98 (95% CI of 1.06∼3.71) for risk for pulmonary TB in patients with CWP. There was a synergic interaction between the TNF-α-308 GG genotype and body mass index (OR=4.92), as well as an interaction between the TNF-α-308 GG genotype and history of BCG immunization or history of TB exposure. And, the interaction of the TNF-α-238 GG genotype and history of BCG immunization or TB exposure with risk for pulmonary TB in them was also indicated.
TNF-α-308 A allele is associated with an elevated risk for pulmonary TB, whereas TNF-α-238 A allele was otherwise.
The burden of HIV and AIDS on blood bank reserves in northeast Nigeria
2007, Transactions of the Royal Society of Tropical Medicine and Hygiene
This study was conducted to evaluate the burden of HIV/AIDS on blood bank reserves at the University of Maiduguri Teaching Hospital, Nigeria, during 1995–2005. The number of admissions due to HIV/AIDS rose from 43 in 1995 to 447 in 2005, and the proportion of blood units used in transfusing patients with HIV/AIDS rose steadily from 3% in 1995 to 19% in 2005. The proportion of blood units used in managing obstetric patients was also high and fluctuated between 36% and 50% during the period of study. Controlling the spread of HIV, effective treatment of patients with antiretroviral drugs and setting up a functional national blood transfusion service could lessen the rising burden of transfusion in Nigeria and improve blood availability for maternal and child health care.
Tuberculosis and HIV Infection
2006, Disease-a-Month
Citation Excerpt :
Currently, the incidence of TB in HIV-infected persons is greater than 100 times that of the general population.8 Approximately 20% of extrapulmonary TB in the U.S. is associated with HIV infection and more than 50% of TB occurring in advanced AIDS is associated with extrapulmonary disease.9,10 HIV-infected persons have increased risk for multi-drug-resistant (MDR) TB.11,12
Miliary tuberculosis: New insights into an old disease
2005, Lancet Infectious Diseases
Citation Excerpt :
No large published series on miliary tuberculosis in patients with HIV/AIDS are available. The clinical presentation of tuberculosis in early HIV infection (CD4+ cell counts >500 cells/μL) is similar to that observed in immunocompetent individuals.83,106,107 With progression of immunosuppression in advanced HIV infection (CD4+ cell counts <200 cells/μL), disseminated and miliary tuberculosis are seen more often.36,108
Miliary tuberculosis is a potentially lethal form of tuberculosis resulting from massive lymphohaematogeneous dissemination of Mycobacterium tuberculosis bacilli. The emergence of the HIV/AIDS pandemic and widespread use of immunosuppressive drugs has changed the epidemiology of miliary tuberculosis. Impaired cell-mediated immunity underlies the disease's development. Clinical manifestations are non-specific and typical chest radiographic findings may not be seen until late in the course of the disease. Atypical presentations—eg, cryptic miliary tuberculosis and acute respiratory distress syndrome—often delay the diagnosis. Several laboratory abnormalities with prognostic and therapeutic implications have been described, including pulmonary function and gas exchange impairment. Isolation of M tuberculosis from sputum, body fluids, or biopsy specimens, application of molecular methods such as PCR, and histopathological examination of tissue biopsy specimens are useful for the confirmation of diagnosis. Although response to first-line antituberculosis drugs is good, evidence regarding optimum duration of treatment is lacking and the role of adjunctive corticosteroid treatment is unclear.
Cytokine responses induced by Mycobacterium tuberculosis in patients with HIV-1 infection and tuberculosis
2005, International Journal of Infectious Diseases
Tuberculosis (TB) is an important opportunistic infection in HIV patients. Immune responses to Mycobacterium tuberculosis in HIV/TB patients were evaluated.
Fifteen patients with HIV/TB, ten with HIV, four with TB, and five controls were enrolled. Peripheral blood mononuclear cells were isolated and stimulated with mycobacterial antigen (PPD). Interferon (IFN)-γ and TNF-α in culture supernatants were measured by ELISA.
IFN-γ and TNF-α production after PPD stimulation was markedly decreased in HIV patients, but not in HIV/TB patients. In HIV patients with a CD4 cell count of less than 200/mm³, IFN-γ and TNF-α production after PPD stimulation was higher in HIV/TB patients than in HIV patients. Cytokine responses to M. tuberculosis reconstituted after highly active antiretroviral therapy (HAART) and were prominent in HIV/TB patients.
Cytokine responses to M. tuberculosis were retained in HIV-infected patients with tuberculosis, even in patients with a CD4 cell count of less than 200/mm³, and reconstituted after HAART.

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ReviewTuberculosis and acquired immunodeficiency syndrome: A historical perspective on recent developments

Abstract

Chest

Chest

Chest

Chest

Chest

Am J Med.

Chest

Am J Med.

Chest

Lancet

Tubercle

Am J Infect Control

Tuberculosis: a global overview of the situation today

Bull WHO

HIV prevalence estimates and AIDS case projections for the United States: report based upon a workshop

MMWR

Cursed duet: HIV infection and tuberculosis

Respiration

Tuberculosis in patients with human immunodeficiency virus infection

NEJM

Tuberculosis morbidity in the United States: final data, 1990

MMWR

Tuberculosis: commentary on a reemergent killer

Science

Epidemiology of extra-pulmonary tuberculosis among persons with AIDS in the United States

Clin Infect Dis.

Tuberculosis in the United States

JAMA

Tuberculosis in the AIDS era: a new threat from an old disease

NY State J Med.

Treatment of tuberculosis in patients with advanced human immunodeficiency virus infection

NEJM

Risk stratification for dissemination of tuberculosis in HIV-infected patients

Q J Med.

Acquired immune deficiency in Haitians: opportunistic infections in previously healthy Haitian immigrants

NEJM

Tuberuculosis, atypical mycobacteriosis, and the acquired immunodeficiency syndrome among Haitian and non-Haitian patients in South Florida

Ann Intern Med.

The radiographic appearance of tuberculosis in patients with the acquired immune deficiency syndrome (AIDS) and pre-AIDS

Am Rev Respir Dis.

Revision of the CDC surveillance case definitions for acquired immunodeficiency syndrome

MMWR

1993 revised certification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults

MMWR

A prospective study of the risk of tuberculosis among intravenous drug users with human immunodeficiency virus infection

NEJM

Human immunodeficiency virus infection in tuberculosis patients

J Infect Dis.

Field Services Branch

Nosocomial epidemic of active tuberculosis among HIV-infected patients

Lancet

An outbreak of tuberculosis with accelerated progression among persons infected with the human immunodeficiency virus

NEJM

Transmission of HIV-associated tuberculosis to healthcare workers

Infect Control Hosp Epidemiol.

Mycobacterium tuberculosis transmission in healthcare settings: is it influenced by coinfection with human immunodeficiency virus?

Infect Control Hosp Epidemiol.

Nosocomial transmission of multidrug-resistant Mycobacterium tuberculosis: a risk to patients and health care workers

Ann Intern Med.

Nosocomial transmission of multidrug-resistant tuberculosis among HIV-infected persons — Florida and New York, 1988–1991

MMWR

Clinical presentation and outcome of patients with HIV infection and tuberculosis caused by multipledrug-resistant bacilli

Ann Intern Med.

Nosocomial transmission of drug resistant tuberculosis, New York

Transmission of multidrug-resistant tuberculosis from an HIV-positive client in a residential substance-abuse treatment facility—Michigan

MMWR

Exogenous reinfection with tuberculosis in a shelter for the homeless

NEJM

Human immunodeficiency virus infection among homeless men in a New York City shelter

Arch Intern Med.

Drug resistant tuberculosis among the homeless in New York City

NY State J Med.

Review
Tuberculosis and acquired immunodeficiency syndrome: A historical perspective on recent developments