MYCOBACTERIAL COMPLICATIONS OF HIV INFECTION
Section snippets
FREQUENCY OF COEXISTING TUBERCULOSIS AND HIV INFECTION
At least four factors influence the rate of tuberculosis among HIV-infected populations: (1) the prevalence of latent infection with M. tuberculosis in the population; (2) the likelihood of exposure to persons with infectious tuberculosis; (3) the range of severity of immune compromise in the population and, thus, the likelihood of developing tuberculosis if infected with the organism; and (4) the frequency of use of isoniazid greatly reduces the risk for tuberculosis. These factors and perhaps
EFFECTS OF HIV INFECTION ON THE PATHOGENESIS OF TUBERCULOSIS
Tuberculosis develops by direct progression from recently acquired infection or by reactivation of latent infection. Because HIV impairs the ability to contain a new tuberculous infection, the risk of direct progression is much greater among persons with HIV infection; thus, an increasing number of cases may be occurring via this mechanism. Recent population-based studies of the molecular epidemiology of tuberculosis suggest that direct progression from infection to disease may be more common
Tuberculin Skin Testing and Anergy Testing
Because of the suppression of cell-mediated immunity, the tuberculin skin test commonly shows little or no reaction in persons with advanced HIV infection who also are infected with M. tuberculosis. In earlier stages of HIV infection, however, reactivity may be maintained. In a study reported by Markowitz and co-workers,92 the prevalence of positive (≥ 5-mm induration) tuberculin skin tests decreased progressively as the CD4+ cell count decreased, and the prevalence of anergy, as measured by
TREATMENT
Most reported series of patients with tuberculosis and HIV infection show a good response to antituberculosis treatment when regimens containing isoniazid and rifampin are used.10, 28, 116, 117, 118, 133, 139, 142 In a study from Zaire, the cure rate of a 6-month regimen was equal in HIV-infected and uninfected patients, but it was shown that administration of isoniazid plus rifampin for an additional 6 months was associated with a decreased rate of apparent relapse.113 Reinfection, however,
TUBERCULOSIS CAUSED BY MDR ORGANISMS
Explosive outbreaks of tuberculosis caused by MDR organisms (resistant to at least isoniazid and rifampin) have been reported.41, 44, 79 These outbreaks have taken place in hospitals and clinics and have predominantly involved HIV-infected patients.11 Health care workers, both HIV-seropositive and seronegative, have been infected. Substantial epidemiologic and laboratory DNA fingerprinting data indicate that transmission of the resistant M. tuberculosis has taken place in the health care
PREVENTION
The effectiveness of isoniazid preventive therapy in persons infected with HIV and M. tuberculosis was substantiated in a study conducted in Haiti by Pape and co-workers.110 In this study, administration of isoniazid, 300 mg/d for 12 months, significantly decreased the incidence of tuberculosis compared with placebo. Among newly identified HIV-infected persons who were without symptoms, rates of tuberculosis were 2.2 per 100 person-years for those given isoniazid compared with 7.5 per 100
NONTUBERCULOUS MYCOBACTERIAL DISEASES
Before the onset of the AIDS epidemic, disseminated nontuberculous mycobacterial disease was uncommon.70, 150 Between 1981 and 1987, more than 2000 cases of disseminated nontuberculous mycobacterial infections in HIV-infected patients were reported to the Centers for Disease Control and Prevention; 96% of these infections were due to MAC, another 2.9% were due to M. kansasii, and less than 1% were due to other nontuberculous mycobacteria.69 With improved survival because of the use of antiviral
Epidemiology
Disseminated MAC disease is the most common systemic bacterial infection in HIV-infected persons. In prospective cohort studies, 25% to 35% of all HIV-infected persons eventually developed disseminated MAC disease, making it the second most common opportunistic infection in this population.66, 76 The risk of disseminated MAC disease depends on the severity of cell-mediated immunodeficiency. In a prospective study, the 1-year actuarial incidence of MAC bacteremia was 3% among subjects with CD4+
OTHER NONTUBERCULOUS MYCOBACTERIA
Although nontuberculous mycobacteria other than MAC have been identified as causing infection in HIV-infected patients, their incidences have been relatively low, accounting for less than 4% of disseminated nontuberculous mycobacterial disease reported to the Centers for Disease Control and Prevention.69 Because of limited clinical experience with these organisms in HIV-infected patients, recommendations regarding management and treatment are primarily based on small series, anecdotal reports,
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Address reprint requests to Daniel P. Chin, MD, MPH, Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, 1001 Potrero Avenue, Room 5K1, San Francisco, CA 94110