Tubercolosi e HIV

1
Clinical case on TB/HIV co-infection
2

• Male, 44 years old, previously drug-addict, AIDS
  presenter (esophageal candid?sis) develops
  respiratory signs and buboes at cervical,
  mediastinal and abdominal sites
• Viro-Immunological parameters
• CD4102 cell/?L HIV-RNA23145cp/mL.

3
Clinical case

• What is the most likely diagnosis in this case ?
• Disseminated TB
• Lymphoma
• Disseminated hystoplasmosis
• Disseminated Mycobacterium avium infection

4
DISCUSS DIFFERENTIAL DIAGNOSIS OF THESE
CONDITIONS AND RELEVANT STANDARD DIAGNOSTIC
PROCEDURES Discuss probability of disseminated
TB disease in HIV compared to HIV Discuss
implications of CD4 cell counts on clinical
presentation of TB
5
Clinical case

• Should HAART be started ? When ?
• Start TB therapy and HAART at same time
• Start TB, wait two weeks and start HAART
• Start TB, wait two months and start HAART
• Do not start HAART at any time of TB therapy

6
DISCUSS NATIONAL AND INTERNATIONAL
RECOMMANDATIONS FOR TB AND HIV COMBINED
THERAPY Discuss rational for early initiation of
HAART during TB therapy in termds of reduction of
mortality and morbidity Discuss problems of
early initiation of HAART during TB therapy in
terms of side effects, drug-drug interactions,
reduced adherence, immune reconstitution syndrom
7
Clinical case

• Which TB regim should you start ?
• Isoniazide rifampicin ethambutol
  pyrazinamide for 12 months
• Isoniazide rifampicin ethambutol
  pyrazinamide for 2 months followed by isoniazide
  rifampicin for 4-7 months
• Isoniazide rifabutine ethambutol
  pyrazinamide for 2 months folowed by isoniazide
  rifabutine for 4-7 months
• Isoniazide rifampicin ethambutol for 2 months
  followed by isoniazide rifampicin for per 4
  months
• Isoniazide rifampicine ethambutolciprofloxaci
  ne for 2 months followed by isoniazide
  rifampicin for 7 months

8
DISCUSS NATIONAL AND INTERNATIONAL
RECOMMANDATIONS FOR TB THERAPY IN HIV INFECTED
PATIENTS Discuss lenght of therapy for TB
9
Clinical case
A standard TB regimen is started isoniazide
rifampicin ethambutol pyrazinamide Two weeks
thereafter the patient is in stable clinical
conditions, with no major side effects to TB
therapy. An HAART regimen is started
10
Clinical case

• Which HIV drug classess should you use ?
• 2NRTI
• 3NRTI
• 2NRTI NNRTI
• 2NRTI PI

11
Clinical case

• Which specific regimen should you use ?
• Didanosine lamivudine efavirenz
• Zidovudine lamivudine abacavir
• Tenofovir lamivudine lopinavir/ritonavir
• Tenofovir lamivudine efavirenz
• Tenofovir atazanavir Fosamprenavir/ritonavir

12
DISCUSS CRITERIA FOR SELECTION OF CLASSES OF
DRUGS FOR HIV THERAPY Discuss drug interactions
between rifampicin and HIV drugs and relevant
clinical implications Discuss national and
international recommandations on HIV regimens for
patients assuming TB therapy
13
Caso clinico

• The following regimen is started
• Stavudine lamivudine efavirenz (800 mg
  patient body weight is 62)
• The follow-up of the patient is characterised by
  onset and persistance (at 1 month evaluation) of
  the following symptoms
• Sleeplessness, nightmares, dizziness, anxiety,
  lower limbs pain)
• The patients reports reduction of adherence to
  therapy

14
DISCUSS ADVERSE EVENTS OF COMBINED THERAPY WITH
DRUG-SPECIFIC SIDE EFFECTS DISCUSS IMPLICATIONS
FOR ADHERENCE
15
Clinical case

• How to intervene?
• Treatment should continue with no variations
• HAART should be interrupted
• The dose of efavirenz should be reduced from
  800mg/day a 600mg/day
• Measure efavirenz blodd levels (TDM) to assist
  with the choice

16
Clinical case
Teatment is continued with no changes Four
months after start of TB therapy the chest X-ray
is improved (put image), lymphonodes have almost
disapperead The viral load for HIV demonstrate a
spike (9876 / mL) after initial reduction below
detection threshold. CD4 cell counts are 120
cell/?L
17
Clinical case

• How to interpret the situation ?
• The patient is non-adherent to HAART and has
  developed failure of HIV Therapy
• Falure of HIV therapy is due to drug interactios
  between rifampicin and HIV drugs

18
DISCUSS IMPACT OF POOR ADHERENCE TO HIC THERAPY
DISCUSS SPECIFIC CHARACTERISTICS OF EFAVIRENZ
AND ACQUISITION OF DRUG RESISTANCE DISCUSS
ALTERNATIVE REGIMENS FOR HIV THERAPY IN PATIENTS
ASSUMING TB THERAPY
19
Clinical case

• The patient is shifted to the followign HIV
  therapy
• zidovudine lamivudina abacavir
• At months 5 after start of TB therapy the
  patient develop new buboes at cervical site (PUT
  IMAGES)
• The VL is below detection threshold and CD4 cell
  counts are 130 cell/mL

20
Clinical case

• How to interpret ? How to react ?
• It is the normal evolution of TB. Treatment
  continues unchanged
• It is the immune reconstitution syndrom
  anti-inflammatory therapy including steroids
  should be started but HIV and TB treatment remain
  unchanged
• It is the immune reconstitution syndrom HIV
  treatment should be stopped
• It is a sign of multi-drug resistant TB

21
DISCUSS THE IMMUNE RECONSTITUTION SYNDROM
(IRIS) DISCUSS TREATMENT OF IRIS DISCUSS HOW TO
RULE OUT MDR TB