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Prevalence of pulmonary tuberculosis in HIV positive individuals and its association with [CD.sub.4] count.

INTRODUCTION: AIDS, the Acquired Immunodeficiency Syndrome, is the disease known to be scourge for our century has had an impact like no other disease. Human Immunodeficiency Virus (HIV) affects the human Helper T lymphocytes and macrophages, which are important in maintaining cell mediated immunity (CMI). The CMI is essential in protecting persons from many diseases including tuberculosis. HIV is the most important known risk factor that promotes progression to active tuberculosis in people with Mycobacterium tuberculosis infection. (1) Tuberculosis (TB) and HIV have been closely linked since the emergence of AIDS. The lifetime risk of tuberculosis in immune competent persons is 5% to 10%, but in HIV positive individuals, there is a 5% to 15% annual risk of developing active TB disease. (2) The estimated prevalence of bacteriologically positive TB (Smear and/or culture) is 249 per 100,000 for India. (3) The pattern of clinical presentation of TB depends on the host immune status which is reflected in the microbiological, radiological and histological characteristics of TB.

The [CD.sub.4] T-cell count is one of the best indicators of the immediate state of immunologic competence of the patient with HIV infection. The appearance of many opportunistic infections correlates with the [CD.sub.4] count. TB generally develops at [CD.sub.4] counts of 200-500 cells/mm. (3) Thus determinations of [CD.sub.4] cell counts provide a powerful tool for determining prognosis and monitoring response to HAART. (4)

Therefore the present study has been undertaken to know the prevalence of Pulmonary Tuberculosis (PTB) in HIV positive individuals, to diagnose pulmonary tuberculosis in HIV positive individuals using conventional staining methods (Ziehl Neelsen stain), culture (Lowenstein-Jensen) and radiological evidence, and to study the correlation of pulmonary tuberculosis with the [CD.sub.4] cell counts in HIV positive individuals.

MATERIAL & METHODS: The Prospective Hospital Based Study was conducted in the Department of Microbiology, from November 2007 to October 2009 in association with the ART clinic, Medicine, Integrated Counseling & Testing Centre, Chest and TB wards of our hospital.

A total of 362 known HIV positive patients of 18 years of age and above either hospitalized or coming to ART clinic, clinically suspected of having pulmonary tuberculosis, after written informed consent, were included in the study. The patients with extra pulmonary manifestations were excluded from the study.

Two sputum samples were obtained from each patient as per RNTCP guidelines. (5) Smears were prepared and stained by Ziehl Nielsen stain. The culture was done on Lowenstein-Jensen medium (LJ) The growth was identified by standard methods. (6)

About 3 ml of blood was collected from each patient using aseptic precautions in EDTA vacutainers. [CD.sub.4] counting of blood samples was done by Flow cytometry as per manufacturer's instructions (FACS Calibur, Becton-Dickinson, Immunocytometry system). The findings of the chest X-ray were noted of each patient. Correlation of [CD.sub.4] cell counts was done with the pulmonary tuberculosis in HIV positive patients.

RESULTS: Out of 362 patients, a total of 85 (23.48%) were diagnosed as Pulmonary tuberculosis patients by radiology, Z.N. staining and culture. The tuberculosis patients according to their occupation are shown in Table 1.

Of the 85 Pulmonary tuberculosis cases 34(40.0%) were positive by culture and/or smear along with radiology and 51 (60.0%) were diagnosed by radiology alone. Table 2 shows the correlation between the results of Z. N. stain and Culture.

Of the total 85 PTB cases, in 34 (40%) patients Mycobacteria were isolated by culture. Of the 34 isolates 33 were M. tuberculosis complex and 1 was Rapid grower (Atypical Mycobacteria). Of the 85 Pulmonary tuberculosis cases 48 (56.47%) had [CD.sub.4] counts of less than 200, in 28 (32.94%) between 200 & 349, in only 6 (7.06%) between 350 & 500 and in only 3 (3.53%) cases the [CD.sub.4] counts were more than 500 cells/[micro]l. The association of [CD.sub.4] counts with occurrence of PTB is shown in Table 3.

DISCUSSION: AIDS is a pandemic of 21st century and pulmonary tuberculosis is the most common opportunistic infection (AIDSCAP). (7) it is important to identify PTB at an earliest so that it can be managed appropriately and at the right time. The prevalence of PTB among the HIV positive persons, in the present study is 23.48 per cent. The prevalence of co-infection with HIV varies widely across regions (8,9,10,11,12,13) within India and outside India mainly due to the variation in the distribution of risk factors, geographic location, awareness levels etc. of the study population.

In the present study, amongst these HIV/PTB co infected, as many as 29 (34.12%) were laborers by occupation followed by drivers 17 (20%). Thus laborers and drivers among AIDS patients had a significant association (p=0.023) with the risk of developing TB. Moreover, TB is still a disease of the poor and the low socio-economic background particularly among the developing countries.

The diagnosis of PTB is based on Radiological findings supplemented by the microbiology tests. The Z. N. stain is simple, economical and rapid but culture is more sensitive than staining. Besides this, culture enables us to identify the strain and also to do the susceptibility testing. The culture isolates in the present study were mostly M. tuberculosis.

The appearance of many opportunistic infections (OI's) correlates with the [CD.sub.4] cell count. In PTB patients to the depletion of [CD.sub.4] counts bear a direct correlation with acquisition of disease. Tuberculosis has a direct association with cell mediated immunity (CMI). The [CD.sub.4] counts are an important indicator of CMI status of an individual. The data in the present study indicates that the patients with [CD.sub.4] counts of less than 350/^l are at substantially higher risk of acquiring PTB. Similar correlation was reported by other Indian and foreign studies. (14,15,16) Since HIV/AIDS leads to immunosuppression, it is strongest of all known risk factors for development of TB. Thus, the patients who have [CD.sub.4] count <350 cells/[micro]l have significantly more chances of acquiring TB (p=0.001) confirming further the importance of [CD.sub.4] counts.

Thus, the results of the present study emphasizes that co-infection of TB has been a major concern in HIV/AIDS patients. TB remains an important public health problem and has been exacerbated by the HIV epidemic, resulting in increased morbidity and mortality worldwide. HIV-TB co-infection is "Bidirectional and synergistic" and is often designated as "Cursed Duet". HIV/AIDS leads to immune suppression and is a strongest of all known risk factors for the development of TB and there is need for constant monitoring of HIV positive patients for acquisition of TB, assessment the type of prevalent mycobacteria in the region and information on the resistance pattern obtained in the prevalent strains.

DOI: 10.14260/jemds/2015/447

REFERENCES:

(1.) World Health Organization: Background information on tuberculosis and Human Immunodeficiency Virus: Impact of HIV on TB control. In: TB/HIV: A clinical manual/writing team: Harries A, Maher D, Graham S. 2nd ed. WHO.2004.

(2.) Swaminathan S, Ramachandran R, Baskaran G, Paramasivan CN, Ramanathan U, Venkatesan P et al: Risk of development of tuberculosis in HIV infected patients. Int J Tuberc Lung Dis 2000; 4:839-44.

(3.) World Health Organization: Global tuberculosis control: WHO Report 2010. https//www.who.int/tb/publications/global.report

(4.) Fauci AS, Lane HC. Human Immunodeficiency virus (HIV) disease: AIDS and related disorders. In: Harrison's Principles of Internal Medicine vol. 1. 16thed. Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL, editors. Mc Graw Hill, New Delhi. 2005:1076-1139.

(5.) Central TB Division & National AIDS Control Organization: Training Module for Medical Officers on TB/HIV: Programme Objectives. NACO, New Delhi: 2005; 14-17.

(6.) Collee JG, Duguid JP, Fraser AG, Marmion BP, Simmons A: Laboratory strategy in the diagnosis of infective syndromes. In: Mackie and McCartney Practical Medical Microbiology-14th ed. Collee JG, Fraser AG, Marmion BP, Simmons A, editors. Elsevier (Churchill Livingstone), New Delhi. 2006; 53-94.

(7.) AIDS Control and Prevention (AIDSCAP) Project of Family Health Internal: The Status and Trends of the Global HIV/AIDS Pandemic. Final Report July 5-6. The Francois-Xavier Bagnoud Center for Public Health and Human Rights Of the Harvard School of Public Health, UNAIDS., 1996.

(8.) Dhungana GP, Ghimire P, Sharma S, Rijal BP: Tuberculosis co-infection in HIV infected persons of Kathmandu.Nepal Med Coll J 2008;10(2):96-9.

(9.) Saini A, Bajaj L, Ranjan R: Prevalence and clinico-radiological profile of TB in HIV seropositive patients. Int Conf AIDS. 2004 Jul 11-16; 15.

(10.) Maniar JK, Kamath RR, Mandalia S, Shah K, Maniar A: HIV and Tuberculosis: partners in crime.Indian J Dermatol Venereol Leprol 2006;72(4):276-82.

(11.) Chakraborty N, Mukherjee A, Santra S, Sarkar RN, Banerjee D, Guha SK et al: Current trends of opportunistic infections among HIV-Seropositive patients from Eastern India. Jpn J Infect Dis 2008; 61:49-53.

(12.) Praharaj AK, Kalghatgi AT, Varghese SJ, Nagendra A: Incidence and Drug Susceptibility pattern of Mycobacterium tuberculosis in HIV infected Patients. MJAFI 2004; 60:134-36.

(13.) Mahajan A, Tandon VR, Verma S, Singh JB, Sharma M: Prevalence of tuberculosis, hepatitis B, hepatitis C and syphilis co-infections among HIV/AIDS patients. Indian J Med Microbiol 2008; 26:196-7.

(14.) Markowitz N, Hansen NI, Hopewell PC, Glassroth J, Kvale PA, Mangura BT et al: Incidence of tuberculosis in the United States among HIV-infected persons. Ann Intern Med 1997; 126:123-32.

(15.) Lee Man Po, Johnny Wai Man Chan, Ka Kui Philip Ng, Patrick Chung Ki Li: Clinical manifestations of tuberculosis in HIV-infected patients. Respirology 2000; 5:423-6.

(16.) Vajpayee M, Kanswal S, Seth P, Wig N: Spectrum of Opportunistic Infections and Profile of CD4+Counts among AIDS Patients in North India. Infection 2003; 31(5):336-40. Sudha Mishra [1], Meena Mishra [2], Atul R. Rukadikar [3], A. M. Kurhade [4]

AUTHORS:

[1.] Sudha Mishra

[2.] Meena Mishra

[3.] Atul R. Rukadikar

[4.] A. M. Kurhade

PARTICULARS OF CONTRIBUTORS:

[1.] Senior Resident, Department of Microbiology, Government Medical College, Nagpur.

[2.] Assistant Professor, Department of Microbiology, Government Medical College, Nagpur.

[3.] Senior Resident, Department of Microbiology, Government Medical College, Nagpur.

[4.] Associate Professor, Department of Microbiology, Government Medical College, Nagpur.

FINANCIAL OR OTHER COMPETING INTERESTS: None

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Atul R. Rukadikar, Assistant Professor, Department of Microbiology, Chirayu Medical College and Hospital, Bhopal.

E-mail: atulruks@gmail.com

Date of Submission: 28/01/2015.

Date of Peer Review: 29/01/2015.

Date of Acceptance: 20/02/2015.

Date of Publishing: 27/02/2015.
Table 1: Prevalence of Tuberculosis in different occupations of
HIV positive patients (n=362)

Occupation        No. of patients (n)   No. of Tuberculosis
                                            patients (%)

Laborers                  143               29 (34.12%)
Housewives                75                14 (16.47%)
Drivers                   52                17 (20.0%)
Farmers                   11                 1 (1.18%)
Job                       52                11 (12.94%)
Miscellaneous *           29                13 (15.29%)
Total                     362                85 (100%)

* Salesman, Painter, Electrician,
Welder Carpenter, Police Shopkeeper, Barber, Students, Hawkers
etc.

Table 2: Correlation between ZN staining and culture (n=362)

ZN stain               Culture on LJ medium      Total (%)
                       Positive    Negative

           Positive      28           0           28 (7.73)
           Negative       6          328         334 (92.27)
           Total (%)   34 (9.39)   328 (90.61)   362 (100)

Table No. 3: Correlation of CD4 count in HIV/PTB co infected
cases

Counts:          HIV with PTB   HIV without PTB   Total
Cells/[micro]1        (%)              (%)         (%)

<200               48 (44.86)     59 (55.14)      107 (100)
200-349            28 (31.46)     61 (68.54)       89 (100)
350-500             6 (7.89)      70 (92.11)       76 (100)
>500                3 (3.33)      87 (96.67)       90 (100)
Total              85 (23.48)    277 (76.52)      362 (100)
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Title Annotation:ORIGINAL ARTICLE
Author:Mishra, Sudha; Mishra, Meena; Rukadikar, Atul R.; Kurhade, A.M.
Publication:Journal of Evolution of Medical and Dental Sciences
Date:Mar 2, 2015
Words:1949
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