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Tuberculosis and HIV - Management of a Deadly Dyad

TB management in high-HIV prevalent areas is a skill required of physicians practicing in the developing world.
by

Michael Tuggy

on 24 April 2013

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Transcript of Tuberculosis and HIV - Management of a Deadly Dyad

Tuberculosis and HIV Managing the Deadly Dyad Case 1: Shortness of Breath 37 y.o. East African male with shortness of breath, tachypnea and marked work of breathing noted for the past 3 days. He also reports fatigue and weight loss for the past 3 months.
ROS: denies cough, positive for subjective "hotness of the body". No sputum, no diarrhea, denies any history of STD's. Physical Exam: Exam: afebrile, BP 90/72,P=110, RR 52, T= 40.1 C, O2 sat = 41% on room air.
MS – arousable, not coherent,
Thin, wasted appearance
Chest – Bilateral rales, + retractions
CV – RRR, tachycardic
Neuro – Normal DTR’s, no focal weakness or sensory changes Chest X-Ray What are the top 3 infections
in your differential that could
cause this clinical picture? TB
PCP Pneumonia
Community-acquired Pneumonia How do you differentiate between these three infections? TB
PCP
CAP In the meantime you order labs:
CBC: HCT =24.9, WBC 9.2
HIV Rapid Assay: POS
CD4: 6
LP - no cells, protein 43, glucose = 86 Write out your initial treatment plan?
- IV orders
- Medications
- Supportive measures Assume you are treating broadly for infection initially- how else can you improve his hypoxia? What other medication might
be helpful in this case? TB commonly has a history of weight loss, sweats, fevers. Cough in patients with AIDS is not prominent while significant wasting is a major hallmark of TB. PCP is characterized by profound hypoxia, which is not a feature of TB except in late stages. Dual infection is possible in very immunosuppressed patients. Bilateral perihilar infiltrates are classic for PCP, but TB can have a similar appearance. Wasting is not a key feature of PCP infection. Treatment Strategies:
Q5. What prophylactic treatment might you include?
Q6.When would you consider starting HIV treatment with HAART therapy? Treatment Summary Supportive:
Oxygen - 50% non-rebreather mask
RHZE - TB regimen
Bactrim DS - 2 tabs TID
Ceftriaxone 2gm IM/IV
Other: prednisone 40mg PO daily
Careful fluid management (avoid over hydration) - risk of ARDS.
Treatment of HIV with HAART can start in 2 weeks. Treatment Case Study TB and HIV coexist with high rates (>50%) of coinfection in most parts of Africa and Asia

Hallmark of TB infection is weight loss, wasting, extrapulmonary TB is common.

Treatment for suspected cases should be initiated empirically, along with broad coverage for CAP. Treat for PCP if O2 saturations < 90%.

HAART therapy can be initiated after initial 2 weeks of HIV treatment- watch for IRIS response Summary TB and HIV

Michael Tuggy, MD
Swedish Family Medicine - First Hill 1. TB is an indolent disease that is a two-phased infection. In the immune-compromised patient, its presentation is quite different than in the immune competent patient.
2. Cough, X-ray changes may not be prominent in AIDS patients due to lack of inflammatory response. 3.TB commonly is extrapulmonary among HIV infected patients – look for other loci (CNS, pericaridium, bone)
4.The mainstay of treatment: RZHE x 2 months, then 4 months of RH – many variations in protocols but this is core to treatment.
5. IRIS – Immune reconstitution inflammatory syndrome can be fatal if not managed properly. Key Concepts: Key Concepts: Group Questions:
What features are most suggestive of TB?
What exam findings are most concerning
How does this inform your differential What diagnostic and lab studies are essential in a low resource setting? Work up
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