Drug-resistant Tuberculosis in AIDS

Tuberculosis has been recognized as a manifestation of the acquired immunodeficiency syndrome (AIDS) and its treatment has become an important and controversial issue. Many questions regarding adequate number of drugs and length of treatment have not been answered and await long-term, controlled clinical trials. We have recently reviewed the prevalence of drug-resistant Myco­bacterium tuberculosis in our hospital and decided to evaluate it among the growing population of AIDS.

We retrospectively searched our mycobacteriology register for cases of M tuberculosis infection from 1982 to early 1988. Of 137 isolates, 13 had a clinical diagnosis of AIDS or AIDS-related complex, and their clinical records were reviewed.

Of the 13 patients, 11 were men and two women, with a mean age of 38 years; six were Hispanic, three black, three white and one Asian; eight were admitted to non-private services and five acknowl­edged a prior history of tuberculosis. Regarding risk factors and diagnosis criteria: seven were homosexual or bisexual, four were intravenous drug abusers, one was married to an AIDS patient (also with tuberculosis) and one did not have any recognized risk. Two were cases of AIDS-related complex, five had Kaposi’s sarcoma (one in the lung simultaneous with tuberculosis), four had P carinii pneumonia (two concomitant with tuberculosis) and the remaining had other opportunistic infections. Four had a diagnosis of AIDS first; tuberculosis preceded it in three of our 13 cases. At admission, diagnosis of tuberculosis was made in four cases and only considered in four more. Patients had an average of six symptomatic weeks.

Eleven of the 13 cases had infection in the lung, two in the blood, two in bone marrow, one in CSF and one in a lymph node. Chest x-ray examinations showed diffuse interstitial infiltrates in 6 patients and apical infiltrates, with or without cavitation, in only four. Most of the patients were started on therapy with three drugs and did well clinically and radiologically after four weeks of treatment, except for two who died from other complications of AIDS. Three cases (0.23 vs 0.13 in our total tuberculosis population) were resistant to either INH, RMP, EMB or SM, and two of these to both INH and RMP (both patients were homeless). cialis super active

Ten percent of our tuberculosis cases are AIDS-related and most of them have been seen in the last three years. Of the three cases with mycobacteremia, two had AIDS. In only five of our 13 patients was tuberculosis only and alone in the lungs, presenting in half of the cases with diffuse infiltrates on chest x-ray film. Drug resistance was seen in three cases, and in two it was multiple (these patients were homeless, a recognized epidemiologic factor in resistance).One half of the patients in our series were Hispanic, but race did not bear relation to resistance in this small group.

Thus, atypical manifestations of tuberculosis are common in patients with AIDS and related complex, as previously described,but the circumstance is not per se associated to increased drug resistance, and an initial two-drug regimen is probably sufficient when the clinical condition of the patient does not call for aggressive treatment and the risk for drug resistance is otherwise low or absent.