The document discusses HIV/AIDS and tuberculosis (TB). It provides information on HIV, including how it attacks CD4 cells and weakens the immune system. TB is caused by the bacterium Mycobacterium tuberculosis. HIV increases the risk of active TB for those with latent TB infections. Clinical presentation of TB is often atypical in HIV patients. Proper treatment of both HIV and TB is required to improve prognosis. The case presentation is likely extrapulmonary TB involving the pericardium and lymph nodes based on the symptoms and chest x-ray findings.

1. Sonja Hoogendoorn
Ekwendeni Mission Hospital
21-01-2016
HIV/aids and tuberculosis

2. HIV (human immunodeficiency virus)
HIV/AIDS Case presentation Tuberculosis HIV and TB Conclusion References
• RNA virus
• Retrovirus
• Host cell is CD4+ lymphocytes

3. The HIV life cycle
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3) Integration – enzyme integrase
inserts viral DNA in DNA of host cells
1) Binding and entry – proteins recognize CD4+ cells and
attack and invade them
2) Reverse transcription
– enzyme reverse
transcriptase enables the
virus to transform RNA
into DNA
4) Replication – HIV uses host DNA for
synthesis of new HIV proteins

4. HIV
HIV/AIDS
• CD4+ lymphocytes destruction
– CD4+ cells have a shortened life span as a result of the viruses using
them as ‘factories’ to produce 10 million to 10 billion new viruses daily
– Natural immune responses against infected cells (CD8+ T-cells, antibodies,
natural killer cells)
HIV/AIDS Tuberculosis HIV and TB Conclusion References
CD4+ count falls, viral load increases
Cellular immunodeficiency
HIV/AIDS Case presentation Tuberculosis HIV and TB Conclusion References

5. HIV
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• Weakened immune system
• High risk of opportunistic infections and malignancies
Acquired immunodeficiency syndrome (AIDS)
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6. Case presentation
• 41-year-old HIV-infected male, CD4
count unknown, not on ART, no co-
trimoxazole prophylaxis
• Coughing since 5 weeks, antibiotics
given without improvement
• T37.9, P111 bpm, RR 26, palpable
enlarged (2 cm) cervical and axillary
lymph nodes. Chest clear.
• Sputum smear negative twice
• Normal pneumonia
• PCP
• TB
• ..
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Chest x-ray: infiltrate,
large heart
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7. WHO clinical staging
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8. Tuberculosis (TB)
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• Mycobacterium tuberculosis
– Transmission through air (cough, sneeze, talk, spit)
• Active vs latent (‘sleeping’) TB infection
– 1/3 of the world population is infected with M. tuberculosis
– Compromised immune system > reactivation (‘tuberculosis wakes
up’) > progression to active TB disease
• Pulmonary TB vs extra-pulmonary TB (EPTB)
– EPTB: pleura, lymph nodes, meninges, pericardium, etc.
– PTB: person infects on average 10-20 people
HIV/AIDS Tuberculosis HIV and TB Conclusion References
= HIV/aids
HIV/AIDS Case presentation Tuberculosis HIV and TB Conclusion References

9. HIV and TB
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• The risk of active TB in individuals with latent infection is
increased 20-fold by HIV coinfection (WHO, 2009)
– Without ART, 30% of those with latent TB will develop active TB at
some point during their lives (AIDS, 2001)
– It can occur in every range of CD4 counts
• About 56% of TB patients are HIV-positive (2013)
HIV/AIDS Tuberculosis HIV and TB Conclusion ReferencesHIV/AIDS Case presentation Tuberculosis HIV and TB Conclusion References

10. Clinical TB suspect
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• Any of the following current symptoms of any duration:
cough, fever, weight loss, night sweats.
• Other symptoms:
• Respiratory symptoms (shortness of breath, chest pains,
haemoptysis)
• Constitutional symptoms (loss of appetite)
• Most HIV patients with TB do not have typical TB symptoms
– Absence of fever or cough does not rule out TB
– The higher the CD4 count, the more typical the presentation
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11. Sputum smear microscopy
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• Smear-positive pulmonary TB
– One bacilli (M. tuberculosis)
• Smear-negative pulmonary TB: most common form of TB in
Malawi
– Inconclusive chest X-ray but a positive HIV test or clinical evidence of
HIV and a clinical presentation compatible with TB
– Abnormalities on chest X-ray consistent with active pulmonary TB
plus a positive HIV test OR no improvement with a course of broad-
spectrum antibiotics
• HIV-infected patients with TB are less likely to have positive
sputum smears than HIV-negative TB patients
HIV/AIDS Tuberculosis HIV and TB Conclusion ReferencesHIV/AIDS Case presentation Tuberculosis HIV and TB Conclusion References

12. Chest X-ray
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• Radiographic findings suggestive of TB:
– Upper lobe infiltrates
– Cavitary lesions
– Hilar and/or paratracheal lymphadenopathy
• In HIV infection:
– Lower lobe infiltrates (like bacterial pneumonia)
– A miliary or ‘scattered seed’ like pattern
– Lung cavities are rare
• A normal x-ray does not rule out TB in patients with
compatible symptoms and clinical findings
– In 10-20% of HIV-positive patients with PTB, the chest X-ray is
negative
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13. Perihilar and paratracheal lymphadenopathy
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14. Miliary TB with typical ‘snowstorm’ appearance
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15. Cavitary lesion
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16. HIV/AIDS Tuberculosis Flowchart Artikel Conclusie Discussie Referenties
Extra-pulmonary TB
•22% of all TB cases in Malawi are EPTB
– More in HIV+ patients
Presentation (apart from fever, weight loss and night sweats)
Pleural TB Chest pain, shortness of breath. Absent breath sounds, dullness to
percussion. One sided pleural effusion.
# TB is one of the most common causes of a unilateral pleural effusion
TB meningitis Headache, confusion/coma, altered mental status, neck stiffness
CSF with between 100-500 cells/mm3 with lymphocyte predominance, high
protein and low glucose
# if HIV positive, cryptococcal meningitis is more likely
Pericardial TB Shortness of breath, oedema (swollen legs, abdomen), chest pain
Large heart. Pericardial effusion or pericardial thickening on US
Lymphadenitis TB LN >2 cm in size, painless swelling, localized
# Commonly affects posterior cervical and supraclavicular lymph nodes
Spinal TB/
osteoarticular TB
Back pain, leg weakness, urinary and bowel incontinence (compression of
spinal cord). Slow onset of monoarthritis with low or little pain.
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17. Treatment TB
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Goal: cure patient, prevent death, reduce transmission
•Intensive phase:
• RHZE daily for 2 months (2-5 tablets)
• Rifampicin (R), Isoniazid (H), Pyrazinamide (Z), Ethambutol (E)
•Continuation phase:
• RH daily for 4 months (2-5 tablets)
•If retreatment or TB meningitis, add streptomycin:
• SRHZE daily for 2 months
• RH daily for 7 months
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18. Treatment HIV
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• All TB/HIV co-infected patients should be started on ART
within the first 2 weeks of TB treatment, regardless of CD4
count
• WHO stage 3 or 4
• All HIV-positive TB patients should be started on co-
trimoxazole preventive therapy (CPT)
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19. Prognosis
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• TB is the most common cause of death among HIV-infected
people worldwide
• 1:4 HIV-infected patients dies of TB (WHO, 2009)
• Kenya 1:2, Botswana 2:5, Ivory Coast 1:3, Congo 2:5
• The mortality is higher in smear-negative PTB cases than in
smear-positive cases
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20. Take home message
• TB often presents atypical in HIV-infected patients
• Ask for cough, fever, night sweats and weight loss to all
HIV-infected persons at every clinic visit
• BUT, absence of typical symptoms does not rule out TB
• AND, a negative sputum smear does not rule out TB
• AND, a normal chest x-ray does not rule out TB
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21. Case presentation
• 41-year-old HIV-infected male, CD4
count unknown, not on ART, no co-
trimoxazole prophylaxis
• Coughing since 5 weeks, antibiotics
given without improvement
• T37.9, P111 bpm, RR 26, palpable
enlarged (2 cm) cervical and axillary
lymph nodes. Chest clear.
• Sputum smear negative twice
• Normal pneumonia
• PCP
• TB
• ..
Inleiding Vraagstelling Flowchart Artikel Conclusie Discussie ReferentiesHIV/AIDS Tuberculosis HIV and TB Conclusion References
Chest x-ray: infiltrate,
large heart
HIV/AIDS Case presentation Tuberculosis HIV and TB Conclusion References

22. Case presentation
• TB can cause all of the symptoms:
• Chronic cough
• Large lymph nodes
• Large heart due to pericardial effusion
• PCP causes cough, but not large lymph nodes or large
heart
• US: fluid around the heart
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= smear-negative pulmonary and extrapulmonary
TB involving the pericardium and lymph nodes
HIV/AIDS Case presentation Tuberculosis HIV and TB Conclusion References

23. References
1. Malawi National Tuberculosis Control Programme Manual. Ministry
of Health, Malawi, 2012.
2. Malawi Guidelines for Clinical Management of HIV in Children and
Adults. Ministry of Health, Malawi, 2014.
3. 2015-2020, National Strategic Plan for HIV and aids. National AIDS
commission Malawi, 2014.
4. Jon F. Fielder, MD. Tuberculosis in the era of HIV, a clinical manual
for care providers working in Africa and other resource-limited
settings.
5. HIV Curriculum for the health professional. Baylor College of
Medicine, 2010.
6. Oxford handbook of tropical medicine. Robert Davidson, Andrew
Brent, Anna Seale. Oxford University Press, 2014.
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