The Outcome of ATT In Microbiologically confirmed EPTB-HIV Patients in Tertiary Care Hospital - A Retrospective Study

In the individuals with Tuberculosis and HIV/AIDS, the two pathogens, mycobacteria and HIV potentiate one another and deteriorate immunological function.

Patients are most commonly present with enlarged lymph nodes in the cervical or supraclavicular areas that may be unilateral or bilateral.

Novel diagnostic modalities such as adenosine deaminase levels and CBNAAT can be useful in certain forms of extrapulmonary tuberculosis. In general, the same regimens are used to treat pulmonary and extrapulmonary tuberculosis, and responses to anti-tuberculosis therapy are similar in patients with HIV infection and in those without.

Mycobacterial lymphadenitis: Peripheral lymph node involvement is the commonest form of extra-pulmonary mycobacterial disease, and the cervical region is the most frequently affected site. (1).

Tuberculosis pleural effusion may represent a manifestation of either primary infection or reactivation of latent disease, the latter being more common. Pleural effusions may also be seen with direct contiguous spread of the disease to the pleura or by hematogenous spread. It is now believed that the intense inflammatory reaction obstructs the lymphatic pores in the parietal pleura, causing proteins to accumulate in pleural space with subsequent retention of fluid. Non-productive cough [70%] and chest pain [75%] are the two most common symptoms at presentation. If both cough and pleuritic chest pain are present, the pain usually precedes the cough. Other systemic manifestations include night sweat weakness, weight loss, anorexia and fatigue. Diagnosis include Chest Xray, Computed tomography (CT), Pleural fluid analysis, Acid-fast bacilli smear (AFB), Adenosine deaminase (ADA) levels.

Patients with TB pleural effusion respond well to treatment with standard short-course. Antituberculosis therapy and DOTS is preferred. The use of corticosteroids cannot be recommended and should only be used if acute symptoms, such as fever, chest pain, or dyspnea, are disturbing the patient. If needed, corticosteroids should be prescribed only after the institution of appropriate antituberculosis treatment. Patients can start therapy with 0.5 to 0.75 mg/kg body weight of prednisolone daily until acute symptoms have subsided, with rapid tapering thereafter. Another type of EPTB is Neurological tuberculosis [TB] comprising five to ten percent of the cases of extra-pulmonary TB and occurs more frequently in children. Neurological TB may be classified into three clinicopathological categories: tuberculosis meningitis [TBM], tuberculoma, and arachnoiditis, which is also referred to as TB radiculomyelitis [TBRM].

Tuberculosis meningitis, which accounts for 70 to 80 per cent of cases of neurological TB, is still an important public health problem in developing countries.

Central nervous system [CNS] TB is invariably secondary to TB elsewhere in the body. It is generally believed that the critical event in the development of meningitis is the rupture of a subependymally located tubercle resulting in the delivery of infectious material into the subarachnoid space. Signs and symptoms of meningeal TB include headache, neck stiffness, altered mental status, and cranial nerve abnormalities. Cerebrospinal fluid analysis, Head CT or MRI, Tuberculin Skin Test, Interferon-Gamma Release Assays, Cerebrospinal Fluid Study, Cytology and biochemistry are used as diagnosis techniques. Empiric anti tuberculous therapy should be initiated as soon as clinical, laboratory, or imaging findings suggest tuberculous meningitis.  Antituberculosis therapy is recommended for at least nine to 12 months. Adjunctive corticosteroid therapy with dexamethasone (Decadron) has been associated with reduced fewer neurologic sequelae. The recommended drugs are isoniazid, rifampicin, pyrazinamide and ethambutol or streptomycin. Ethambutol is preferred over streptomycin because of its better CSF penetration. Unless there is a very high suspicion of drug-resistant organism in a particular patient, the proposed four-drug-regimen is generally effective.

Rationale Of The Study

The diagnosis and therefore the management of EPTB is wrought with challenges, when HIV coinfection is present it is indeed ‘double trouble’.

Diagnosis is the foundation on which treatment is based. In EPTB microbiological diagnosis is very difficult and often impossible. Almost always an invasive procedure is required to make a diagnosis. Follow up and response to therapy is based on clinicoradiological means as a repeat sample is unavailable.

Bioavailability of different anti TB drugs in different tissues is different, and many clinicians prolong therapy empirically. Relapse rate especially in lymph node TB has been reported to be high. Since both EPTB and HIV require medications to be taken for long durations compliance is an issue. This study aims to address some of these pertinent issues.

Aim:

To analyze the study outcomes of ATT in Microbiologically confirmed EPTB-HIV patients in tertiary care hospital from retrospective data.

Objectives:

To assess and categorize the outcomes of ATT in EPTB- HIV patients.

To determine and evaluate the therapeutic outcome of EPTB patients treated under program conditions

To study the types of EPTB and assess the most common types of EPTB among study population.

To study the adherence of ART & ATT in EPTB- HIV patients.

MATERIALS AND METHODS

Study Design:

Retrospective study

Study Site: Study was conducted in the Department of pulmonology at (SVRRGGH) Sri Venkateshwara Ramnarayan Ruia Government General Hospital, tertiary care teaching hospital, Tirupati.

Study Duration: 6 months (November 2022 -April 2023)

Time for data collection: 2 months

Time for categorization of results: 2 months

Time for calculating results: 2 months

Study Population:

The study includes 67 patients diagnosed with microbiologically confirmed EPTB-HIV attending ART Centre, after getting clearance from ethical committee of SVMC, Tirupati.

Study Materials: ART+C TPT DATA (Excel sheet)

Exclusion Criteria:

Patients with active pulmonary TB .

Clinically diagnosed EPTB .

Transferred outpatients.

Method Of Data Collection:

A retrospective study was conducted to determine the outcome of TB treatment and the factors associated with EPTB-HIV coinfected patients in SVRRGH, Tirupati.

All the EPTB-HIV co-infected patients who registered in the ART Centre were the source population. The study population was EPTB-HIV patients who are systematically selected from TB-HIV patients registered in the SVRRGH from 2018-2019. All the complete medical records of the TB-HIV co-infected patients who registered in the ART Centre were included. In addition, medical records of the transferred-out patients were excluded. The data were collected through reviewing all the necessary documents (HIV registry, Nikshay ID, telephone contact, HIV registry, and follow up data) of the TB patients using a pre-tested structured data extraction format which was developed by considering the variables to be studied.  A legal permission letter was taken from Sri Padmavathi School of Pharmacy to the selected public hospitals and official permission was obtained from the administration of the hospitals. Furthermore, before reviewing medical records of the TB/HIV coinfected patients, permission was obtained from the TB treatment unit heads.

•  The information of the study was used only for the purpose of the study and is kept confidential. Since the data were collected through review of medical records, there is no harm to the patients and their confidentiality is maintained.

RESULTS 

The relevant information about the patients, including demographic data (age, gender, and residence) and clinical data, was obtained from the ART Centre.

 In this retrospective record analysis study, we collected 530 TB-HIV cases. After excluding 441 cases that are pulmonary TB the rest were 89 EPTB-HIV cases which fit into our study area.

A total of 67 eligible Microbiologically confirmed EPTB cases were extracted and analyzed in this study as eligible cases for the study, while other 22 cases were clinically diagnosed extrapulmonary cases.

Table 1: Gender Ratio In Eptb – Hiv:

Gender ratio in EPTB

• Out of  67 cases, 47 were males (70.14%) & 20 were females (29.85%) [table1]

Table 2: Age Group Of Study Population

From table-2, the most affected age group was 35-51 years with 47 [70.15%] cases followed by 20-34 years and 50-67 years with 19 [28.35%] cases recorded.

Table 3: Survival Status Of Microbiologically Confirmed Eptb-Hiv Patients

From Table-3,we found that 49 patients (73.13%) were alive, 13 cases (19.40%) died, and 5 patients (7.46%) were defaulters (i.e. lost to follow up cases). {table 3}

Table 4: Eptb Types And Percentage

•  Among 67 EPTB-HIV cases, 50.74% were LNTB (34/67), 23.88% were pleural TB (16/67), 7.46% were spinal TB (5/67), 4.47% were meningeal TB (3/67), 4.47% were abdominal TB (3/67), 1.49% prophylaxis (1/67) and lost to follow up with 7.46% cases (5/67). [table 4;]

Table: 5 Number Of Eptb Types In Males And Females

Table 6: Treatment Outcome Of The Study Population

• From Table-6, we identified that 43(64.17%) cases have completed the treatment course, 2 (2.98%) were relapse cases. Thirteen patients (19.40%) died before completing the course, 4 patients (5.97%) were on treatment, 5 patients (7.46%) were defaulters, and all were EPTB-HIV co-infected.

Fig:1 Eptb Percentace In Males And Females

• Males are more predominantly affected compared to females in all types of EPTB.

Fig:2 Art Adherence In The Study Population