European Journal of Cardiovascular Medicine

Tuberculosis (TB) is the most common opportunistic infection associated with HIV in India, posing a significant public health challenge¹. About 60–70% of people living with HIV are likely to develop TB during their lifetime. With nearly 50% of Indian adults infected with “Mycobacterium tuberculosis”, the spread of HIV may lead to a surge in TB cases. HIV weakens the immune system, increasing the risk of latent TB progressing to active disease and susceptibility to reinfection². This interaction intensifies both epidemics, complicating diagnosis, treatment, and control efforts. According to the WHO 2007 report, 79% of HIV positive TB cases occur in the African region, while Southeast Asia, mainly India, accounts for 11%. HIV prevalence among TB patients ranges from 50% to 80% in Sub-Saharan Africa but is significantly lower elsewhere. In India, HIV seropositivity among TB patients varies between 0.4% and 20.1%³. Nearly half of HIV-positive individuals in India are co-infected with TB, and about 200,000 develop active TB annually due to their HIV status^4,5. Tuberculosis (TB), unlike many other opportunistic infections, can occur at any stage of HIV infection, with symptoms varying based on the degree of immune suppression⁶. In developing countries, 25% to 65% of HIV-positive individuals develop active TB, which can affect multiple organs beyond the lungs. Though TB spreads through airborne droplets, it can involve nearly any organ system. Co-infection with HIV and “Mycobacterium tuberculosis” accelerates immune system decline, leading to rapid disease progression and increased mortality if untreated^7,8. HIV significantly increases the risk up to 20 times of latent TB reactivation, while TB may also hasten HIV progression. Additionally, genetic and immune factors may influence susceptibility to both infections. Although HIV adds to the overall disease burden, in India, the spread of tuberculosis is primarily driven by the large number of individuals already infected with TB who are HIV-negative. This indicates that while HIV-TB co-infection is a public health concern⁹, it is not the main contributor to TB transmission in the country. Effective implementation of the Revised National TB Control Programme (RNTCP) is crucial in reducing new TB cases, irrespective of HIV prevalence^10,11. The program emphasizes early diagnosis, standardized treatment, and consistent follow-up. However, co-infection still complicates diagnosis and management due to atypical presentations.^12,13

AIM

Study of Clinical Profile of Tuberculosis in HIV/AIDS patients and its relationship with CD4 count.

The study was conducted in the Department of General Medicine at Mahatma Gandhi Medical College & Hospital, Jaipur, from April 2023 to September 2024. The study population included all HIV-infected patients attending the Anti-Retroviral Treatment (ART) clinic in the Department of Medicine during this period. Inclusion criteria comprised HIV-positive patients of all genders, aged between 18 to 65 years, diagnosed with either pulmonary or extra-pulmonary tuberculosis (EPTB), and who provided informed consent. Patients were excluded if they were above 65 years of age, had sepsis, were known cases of interstitial lung disease (ILD), or declined to give consent for participation.

Table 1: Age parameter of cases

  The table indicates that majority of patients belonged to the age group of 30-39 year

Figure 1,2: Gender and residential profile of cases

In present study, 62.18% were male and 37.82% were female. 45.5% belonged to urban areas and 54.4% belonged to rural areas.

Table 2: Signs of cases

Among the clinical signs observed in HIV-TB co-infected patients, pallor was most common (39.7%), followed by crepitation (24.4%), lymphadenopathy and tachypnea (20.5% each), pedal edema (19.9%), motor weakness (16.0%), oral candidiasis (14.1%), and other signs like hepatomegaly, splenomegaly, hypotension, hypertension, tachycardia, and wheeze observed in varying lower proportions.

Table 3: Symptoms of cases

In HIV-TB co-infected patients, the most common symptoms were fever (87.8%), loss of appetite (69.9%), weight loss (60.3%), cough (54.5%), generalized weakness (48.7%), diarrhea (40.4%), and shortness of breath (34.0%), with less frequent symptoms including neurological manifestations (19.2%), dysphagia (8.3%), and abdominal pain (6.4%).

Table 4: chest x ray finding of cases

Chest X-ray observation was of pleural effusion which was seen in 35.9%, followed by pulmonary infiltrates seen in 17.9% cases. The other chest X-ray observations were cavity and fibrosis both seen in 5.8% cases and miliary lesions seen in 3.8% cases.

Table 5: Distribution of MDR TB in Cases

The table shows that 27 (17.3%) cases have MDR-TB.

Table 6: Distribution of Pulmonary/ Extrapulmonary TB in Cases

Table signifies that out of 156 patients, 60 (38.5%) have Pulmonary TB, whereas 81 (51.9%) have Extra-pulmonary TB and 15 (9.6%) have Disseminated TB.

Table 7: Baseline continuous parameters of cases

Above table shows that mean age of study population was 46.21 ± 11.91 years and mean CD4 count was 141.52 ± 64.72

Figure 3: MDR-TB profile of cases as per Pulmonary/Extrapulmonary TB

The table shows that out of 156 patients, 27 (17.3%) patients of HIV have MDR TB. The number of MDR-TB patients in Abdominal TB, CNS TB, Disseminated TB, Sputum negative Pulmonary TB, Sputum positive Pulmonary TB, and Tubercular Pleural Effusion were 0, 0, 12, 3, 6, 6 respectively and application of statistical test shows that there was significantly higher prevalence of MDR TB in Disseminated TB as compared to other categories.

Table 8: CD-4 count profile of cases as per MDR-TB

Above table shows that mean CD-4 Count of study subjects was 141.52 ± 64.72 cells/mm3 and it was significantly lower in those subjects who have MDR-TB as compared to those who have no MDR-TB. 

In the conducted study, most of the patients were in the 30–39-year age group, followed by the patients of age 60 years and above, followed by patients of 40-49- and 50-59-year age groups. These conclusions match with the observations made by Jaryal et al.¹⁴ who reported majority of tuberculosis cases among HIV-positive individuals, occurring in the 31–40-year age group.

In the conducted study, male participants accounted for 62.2% of the cases and were more prevalent than the female participants comprising 37.8%. Biswajeet Sahoo et al.¹⁵ who also reported a greater proportion of male patients as compared to female patients in their respective studies (62.2% males and 37.8% female patients).

Multiple studies done across low socio-economic countries, including India, have shown consistently a higher incidence of HIV and tuberculosis co-infection among males as compared to females. The results of the current study match with this observed trend. This discrepancy may be due to that men are more likely to seek health care attention and as well as factors such that men who have sex with men (MSM) and other socio-cultural influences ^16,17.

In present study, 54.5% cases belonged to rural residence and 45.5% cases belonged to urban population.

In the present study, fever emerged as the commonest reported symptom, affecting 87.8% of the patients. Second most prevalent symptom was cough seen in 54.5% of cases. Additional symptoms included shortness of breath in 34% patients, loss of appetite in 69.9% and diarrhea in 40.4%. Weight loss was reported by 60.3% of the patients, generalized weakness was reported by 48.7%, abdominal pain by 6.4% and neurological symptoms were seen in 19.2% of the cases. 

In the present study, pallor was reported in 37.7% of patients while lymphadenopathy was noted in 20.5% patients. Pedal edema was reported by 19.9% of cases and tachycardia was seen in 10.3% of cases. Tachypnea occurred in 20.5% of individuals, wheezing in 4.5% and crepitations were heard in 24.4% of the patients. Hypotension was seen in 8.3% and hypertension in 5.8% of the patients. Hepatomegaly and splenomegaly were each reported in 8.3% of cases. Additionally, oral candidiasis was identified in 14.1% of patients and motor weakness was reported in 16% of cases.

In the present study, pleural effusion was the commonest observed finding on chest radiographs, seen in 35.9% of cases, followed by pulmonary infiltrates seen in 17.9% of cases. Other notable abnormalities included cavities and fibrotic changes, both seen in 5.8% of cases, while miliary pattern was seen in 3.8% of cases. Comparable chest radiograph findings were reported by Jaryal et al.¹⁴ M. Manjareeka et al.¹⁸ and Biswajeet Sahoo et al.¹⁵ where pleural effusion, pulmonary infiltrates, cavities and fibrotic changes were frequently observed among HIV-positive patients with tuberculosis, findings that align closely with the current study.

In the present study involving 156 patients, 60 individuals (38.5%) were diagnosed with pulmonary tuberculosis, while 81 patients (51.9%) had extra pulmonary TB (EPTB) and remaining 15 patients (9.6%) presented with disseminated tuberculosis. On the other hand, Jaryal et al. reported different results in their study, where disseminated TB was identified in 17.24% of cases, pulmonary in 25.28% and EPTB in 57.47% of HIV-infected individuals. This difference in comparison to current study can be due to variations in average CD4 count of patients between the two studies.

In present study, mean CD4 cell counts among the participants was 141.52+64.72cells/µl. Notably, individuals diagnosed with disseminated tuberculosis exhibited lowest average CD4 count, suggesting remarkable correlation between advanced immunosuppression and occurrence of severe forms of tuberculosis. Moreover, patients with sputum positive pulmonary TB demonstrated significantly lower CD4 levels as compared to those with sputum negative pulmonary TB. Leeds et al.¹⁹ reported that individuals with CD4 count below 100cells/µl were more susceptible to develop severe extrapulmonary manifestations of TB, including central nervous system involvement, meningeal TB, disseminated disease. These results further corroborate findings of the present study.

In present study mean CD4 count of individuals was 141.52 ± 64.72 cells/mm³ and it was significantly lower in those individuals who had MDR-TB as compared to those who did not have MDR-TB.  Similarly, Jaryal, et al.¹⁴ and Biswajeet Sahoo et al¹⁵ in their studies found that CD4 count were significantly lower in those subjects who had MDR-TB as compared to those who did not have MDR-TB, which is in agreement with results of present study.

HIV infection predominantly affects the younger, economically productive age group. It is commonly seen among individuals involved in high-risk sexual behaviors, including certain professional groups. As CD4 cell count decline, likelihood of co-infection with tuberculosis increases significantly among HIV-positive individuals.

Extra pulmonary tuberculosis was frequently encountered in this population, with pleural effusion, abdominal TB and CNS TB being the most common forms. Traditional diagnostic methods such as tuberculin skin test and sputum examination contributed minimally to the overall diagnosis. Hence, a comprehensive understanding of diverse clinical presentations of tuberculosis in individuals living with HIV is essential for timely and accurate diagnosis. 

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