European Journal of Cardiovascular Medicine

India is the highest Tuberculosis burden country in the world in terms of the absolute number of incident cases that occur each year. It accounts for one-fourth of estimated global incident TB cases in 2015. Tuberculosis prevalence is stable but there have been increased incidents due to increasing incidence of human immunodeficiency virus infection. In patients with retroviral disease and Koch’s disease, the risk of developing tuberculosis is 10% per year. There is a synergistic relationship between HIV and tuberculosis. People living with HIV are more likely than others to become sick with TB. Worldwide, tuberculosis is one of the leading causes of death among people living with HIV. In patients with retroviral disease and Koch’s disease, the risk of developing tuberculosis is 10% per year. According to the World Health Organization global burden in 2018:

• An estimated 8,62,000 people living with HIV (PL HIV) worldwide fell ill with TB in 2018.
• Tuberculosis is the leading cause of death among people with HIV accounting for some 251000 people who died from HIV-associated Tuberculosis in 2018 and about a third of AIDS deaths.
• Globally people living with HIV were 19 times more likely to fall ill with tuberculosis than those without HIV in 2018.

In 2019, TB accounted for an estimated 30% of 690000 related deaths in the world. According to the 2020 global TB report, PLHIV are 18 (15-21) times more likely to develop active TB disease than people without HIV1. In sub-Saharan Africa, incidents of tuberculosis are higher than in India, where 80% of patients with tuberculosis are coinfected with HIV2. In developing countries like India, TB is the most common life-threatening opportunistic infection in patients with10 HIV/AIDS with about 25-65% of patients with HIV/AIDS having tuberculosis of any organ3. The variability among and within routes of HIV exposure depends partly on viral load and on whether the virus is transmitted directly into blood or onto mucus membranes4. HIV, a human retrovirus with tropism for CD4+ T cells and monocytes, induces a decrease in T cell count, and T cell dysfunction and ultimately causes immunodeficiency. HIV also causes B cell dysfunction characterised by polyclonal activation, hypergammaglobulinemia and lack of specific antibody response5.

Aims And Objectives:

• To describe the various clinical manifestations of tuberculosis in people living with HIV and AIDS and correlate it with the degree of immune suppression.

To correlate CD4 cell count and Tuberculosis spread.

Study design: Prospective and observational study.

Study period: One year from the date of 01 March 2021 to 31 March 2022.

Study setting: Department of General Medicine, SVRRGGH, TIRUPATI.

Study subjects: The study population comprised patients attending ART centre and OPD and admitted to the department of medicine with HIV TB co-infection.

Sample size:100

Inclusion criteria:

• Patients who are HIV infected as evidenced by ELISA and with clinical features and radiological features of Tuberculosis supported by CBNAAT or ZN stain for AFB.

Exclusion criteria:

Patients who are

• HIV negative and tuberculosis
• Those who have been diagnosed prior and have already started ATT.
• MDR and XDR tuberculosis
• Patient not willing for follow up
• Patient not willing for the study
• Patient who are too sick and moribund

Advising Routine Investigations like Renal function tests, Liver function tests, CD4

count, Chest X-ray, and Sputum examination by Ziehl-Neelson of Acid-Fast Bacilli (AFB). If extrapulmonary tuberculosis is suspected - advise relevant investigations like Ascitic fluid analysis, Pleural fluid analysis, ultrasound abdomen, CT brain, MRI brain, and MR spectroscopy.

Table 1: Age distribution

Table 1 shows the age distribution. In our present study, 33% of the study subjects were in the age group of 41-50 years, 32%of the study subjects were in the age group of 31-40 years, 21% of the study subjects were in the age group above 50 years, 13% of the study subjects were in the age group of 21-30 years and 1% of the study subjects were in the age group below 20 years.

Table 2: Sex distribution of tuberculosis in PTB and EPTB

Table 2 shows sex distributions in Tuberculosis. In our study both pulmonary and extra-pulmonary TB were diagnosed more in Males than Females.

Table 3: Range of CD4 cell count

Table 3 shows the range of CD4 cell count. In our study about 46% of the patients have CD4 cell count 301-400 cells /mm3, 29% of the patients have 201-300 cells/mm3, 11% of the patients have 101-200 cells/mm3, 8% of the patients have 401-500 cells /mm3 and 6% of the patients have more than 500 cells /mm3.

Table 4: CD4 count in Pulmonary and Extra Pulmonary TB

Table 4 shows the category of TB based on CD4 cell count. In our study in both the category of TB cases, the majority of patients had a CD4 count of 301-400 cells/mm3 followed by 201-300 cells/ mm3 in both groups. Further, it was observed that CD4 count 101-200 cells/mm3 was present among 8 cases in the pulmonary TB group and 3 patients in the extrapulmonary TB group.

The present study was a prospective and observational study of 100 patients done to evaluate the spectrum of tuberculosis in HIV patients and its co-relation to CD4 count. The study was conducted in the Institute of Internal Medicine and ART Centre at Sri Venkateswara Medical College and SVRRGGH for one year on patients admitted to medical wards with HIV-TB co-infection. The main objectives of our study were to describe the various clinical manifestations of TB in people living with HIV and AIDS (PLHA) to correlate it with the degree of immunosuppression and to Correlate CD4 cell count and TB spread. Tuberculosis was the most prevalent of the opportunistic illnesses that afflicted people with HIV and AIDS. Any level of immunosuppression in an HIV-positive person makes them susceptible to tuberculosis. As previously stated in the assessment of the literature, HIV and tuberculosis both hasten the progression of the two diseases. The CD4 cell count provides evidence of the level of immunosuppression.

In our present study, 33% of the study subjects were in the age group of 41-50 years, 32%of the study subjects were in the age group of 31-40 years, 21% of the study subjects were in the age group above 50 years, 13% of the study subjects were in the age group of 21-30 years and 1% of the study subjects were in the age group below 20 years. In our study 57% of the study subjects were males and 43% of the study subjects were females. Similarly, in another similar study done by Jaryal et al., 2011, males were affected more than females (65.51% males and 34.48% females). The most commonly affected age group was 31-40 years and the mean age of the patients was 34.94 years (range 22-56 years).6

In our study about 46% of the patients have CD4 cell count 301-400 cells /mm3, 29% of the patients have 201-300 cells/mm3, 11% of the patients have 101-200 cells/mm3, 8% of the patients have 401-500 cells /mm3 and 6% of the patients have more than 500 cells /mm3. Whereas in the study by Jaryal et al., 2011, Forty-three had CD4 cell count ≤ 100 cells/µl, 71 (81.60%) had CD4 cell count ≤ 200 cells/µl and 16 had CD4 count >200 cells/µl. The mean CD4 cell count was 123 cells/µl (in males 119 cells/µl and females 129 cells/µl)6. In another study by Bakshayesh-Karam et al., 2016, 78.6% had CD4+ counts <350 (mean±SD; 229.15±199.45).7  Whereas in another study by Kesari et al. 2019, 43 (16.04 %) had CD4 cell counts below 300 cells and 4 (0.014 %) each had CD4 cell counts in the range of 300–400 cells and above 400 cells and this relationship was found to be statistically significant on Chi-square test.8 Nearly similar observations are noted in our study.

In our study in both the category of TB cases, the majority of patients had a CD4 count of 301-400 cells/mm3 followed by 201-300 cells/ mm3 in both groups. Further, it was observed that CD4 count 101-200 cells/mm3 was present among 8 cases in the pulmonary TB group and 3 patients in the extrapulmonary TB group. Whereas in the study by Jaryal et al., 2011, all the patients with disseminated tuberculosis had a CD4 count below 200/mm3. Overall, 71 out of 80 (81.60%), seven patients with all forms of tuberculosis had a CD4 count below 200/mm3.6.

The difference in our study could be because of adequate inclusion of hospitalised immune-compromised patients.

1. The most prevalent opportunistic infection among those with HIV and AIDS is tuberculosis (PLHIV).
2. Pulmonary TB is more prevalent than extrapulmonary tuberculosis among the range of tuberculosis that can affect people with HIV. The sensitivity of sputum smear in diagnosing pulmonary tuberculosis in PLHIV is effective.
3. The majority of patients had pulmonary tuberculosis if their CD4 count was higher than 200 cells mm3. Patients primarily had extrapulmonary tuberculosis above the CD4 level of 300 to 400 cells/mm3.
4. The Pleura was the most typical site among the research participants who had extrapulmonary tuberculosis.
5. In the future, CD4 cell count may assist in developing an algorithm for HIV-TB co-infection by helping us to identify the organs frequently damaged by tuberculosis in HIV-positive persons.

1. http://www.southsudanmedicaljournal.com/archive/2009-08/untitled-resource.html
2. https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/hiv/treatment/tuberculosis-hiv
3. Robert Steinbrook, N Engl J Med 2007; 356:1198-1199 DOI: 10.1056/NEJMp078049.
4. Rachel A Royce, Arlene Sena, Willard Cates Jr, Myron S Cohen New England Journal of Medicine 336 (15), 1072-1078, 1997.
5. Javier Chinen, William T Shearer Journal of Allergy and Clinical Immunology 110 (2), 189-198, 2002.
6. Jaryal A, Raina R, Sarkar M, Sharma A. Manifestations of tuberculosis in HIV/AIDS patients and its relationship with CD4 count. Lung India Off Organ Indian Chest Soc. 2011 Oct;28(4):263–6.
7. Bakhshayesh-Karam M, Tabarsi P, Mirsaiedi SM, Amiri MV, Zahirifard S, Mansoori SD, et al. Radiographic manifestations of Tuberculosis in HIV positive patients: Correlation with CD4+ T-cell count. Int J Mycobacteriology. 2016 Dec;5 Suppl 1:S244–5.
8. Kesari SP, Basnett B, Chettri A. Spectrum of Tuberculous Infection in Patients Suffering from HIV/AIDS and Its Correlation with CD-4 Counts: A Retrospective Study from Sikkim. Indian J Otolaryngol Head Neck Surg. 2019 Jun 1;71(2):167–71.