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Symptoms, clinical picture and prognosis of tuberculosis depend on the stage of HIV infection and are determined by the degree of impaired immune response.

ICD-10 code

B20.0 HIV disease with manifestations of mycobacterial infection

Clinical classification of HIV infection

1. stage of incubation.
2. Stage of primary manifestations.

flow options

• A. Asymptomatic.
• B. Acute infection without secondary disease.
• B. Acute infection with secondary diseases.

1. subclinical stage.
2. Stage of secondary diseases.

4A. Less than 10% body weight loss. fungal, viral, bacterial lesions of the skin and mucous membranes, repeated pharyngitis, sinusitis, shingles.

4B. Loss of body weight more than 10%. unexplained diarrhea or fever for more than a month, repeated persistent viral, bacterial, fungal, protozoal lesions of internal organs, localized Kaposi's sarcoma, recurrent or disseminated herpes zoster. Phases.

• progression in the absence of antiretroviral therapy, against the background of antiretroviral therapy;
• remission (spontaneous, after antiretroviral therapy, against the background of antiretroviral therapy).

• progression in the absence of antiretroviral therapy, against the background of antiretroviral therapy;
• remission (spontaneous, after antiretroviral therapy, against the background of antiretroviral therapy).

1. Terminal stage.

In the stage of incubation of HIV infection, before the onset of seroconversion, there is an active reproduction of the virus, which often leads to immunodeficiency. Under conditions of a decrease in the immune response of the body, those infected with mycobacteria during this period may develop tuberculosis, which is often regarded as a manifestation of the late stages of HIV infection (stages 4B, 4B and 5). in this connection, the prognosis is erroneously determined and treatment and dispensary observation that do not correspond to these stages are prescribed.

The beginning of the stage of primary manifestations, proceeding in the form of an acute infection, is noted more often in the first 3 months after infection. It can outpace seroconversion (the appearance of antibodies to HIV in the blood), therefore, in patients with tuberculosis, who are at high risk of HIV infection, it is advisable to re-examine after 2-3 months. The clinical manifestations of tuberculosis in this stage of HIV infection do not differ from those in non-HIV infected patients.

Long-term observation of patients who have had tuberculosis in the stage of primary manifestations shows that after a transient decrease in the immune status, it is restored and the usual treatment of tuberculosis produces a good effect. After completing the main course of treatment, often for many years the general condition of patients remains satisfactory: there are no relapses of tuberculosis, the immune status does not undergo significant changes, and no other secondary diseases occur. HIV infection during this period can bring additional clinical manifestations that need to be differentiated from tuberculosis: enlarged lymph nodes, liver, spleen; diarrhea, meningeal symptoms.

The main clinical manifestation of HIV infection in the latent stage is persistent generalized lymphadenopathy. It must be differentiated from tuberculosis of the peripheral lymph nodes. With persistent generalized lymphadenopathy, the lymph nodes are usually elastic, painless, not soldered to the surrounding tissue, the skin over them is not changed. The duration of the latent stage varies from 2-3 to 20 years or more, but on average it lasts 6-7 years.

Under conditions of continuous replication of the virus in the body of a person infected with HIV, the compensatory capabilities of the immune system at the end of the latent stage decrease and a pronounced immunodeficiency develops. Again, the likelihood of developing tuberculosis increases, while the more pronounced the immunodeficiency becomes. the more tissue reactions to the causative agent of tuberculosis change: productive reactions are lost, alternative reactions with dissemination of the pathogen more and more predominate.

In stage 4A, the first manifestations of secondary diseases characteristic of HIV infection appear. Since immunodeficiency is not expressed during this period, the clinical, radiological and morphological picture, as a rule, does not differ from the picture characteristic of tuberculosis.

In patients in stage 4B, which usually develops 6-10 years after HIV infection, the x-ray picture is increasingly acquiring atypical features.

In stage 4B, even more pronounced deviations from the manifestations typical of tuberculosis appear, the process is characterized by generalization, often with complete absence of changes on lung radiographs. Against the background of a significant immunodeficiency, other secondary diseases develop, which further complicates the diagnosis of tuberculosis.

In general, in the late stages of HIV infection (4B, 4C and 5), disseminated processes and tuberculosis of the intrathoracic lymph nodes predominate (more than 60%) in the structure of forms of tuberculosis.

Often, an x-ray triad is determined: bilateral focal or focal dissemination, an increase in three or more groups of intrathoracic lymph nodes, exudative pleurisy, while rapid dynamics of changes in the x-ray picture, both positive and negative, is possible. Decay cavities in the late stages of HIV infection are detected only in 20-30% of cases, which is associated with a change in tissue reactions against the background of severe immunodeficiency.

A bright clinical picture may precede the appearance of dissemination by 4-14 weeks. in a number of patients on the radiograph, it is not possible to detect changes at all. Among the clinical manifestations, the phenomena of severe intoxication predominate: severe sweating, temperature rises up to 39 ° C. In some cases, patients are worried about a painful cough with very scanty sputum; he may be absent. A third of patients have cachexia.

The percentage of bacterial excretors among patients in the "late" stages of HIV infection is no more than 20-35%, which is associated with a decrease in the number of cases of tuberculosis in the decay phase during this period. Tuberculin tests in the "late" stages of HIV infection in most cases are not informative.

In pathomorphological examination of remote lymph nodes, massive conglomerates with total caseosis are often determined.

In morphological examination, predominantly alternative reactions (necrosis) are recorded - 76%. Dissemination is miliary in nature, in some cases it can be established only by histological examination. Epithelioid and giant cells of Pirogov-Langhans are practically absent, and instead of caseosis typical for tuberculosis, coagulative necrosis and purulent fusion are more often observed. In smears-imprints from these areas, in most cases (72%), a very large amount of Mycobacterium tuberculosis is found, comparable to a pure culture. In this regard, in patients in the late stages of HIV infection (4B, 4C and 5), morphological and bacteriological examination of biopsy specimens is of particular importance for the timely detection of tuberculosis.

Also, for the diagnosis of tuberculosis and other secondary diseases during this period, it is advisable to use the PCR method, which can be used to detect the genetic material of pathogens in the cerebrospinal fluid, pleural fluid, lavage, and biopsy specimens.

The complexity of diagnosing tuberculosis is also due to the fact. that most patients develop other secondary diseases: candidal stomatitis, visceral candidiasis, recurrent herpes, manifest cytomegalovirus infection, HIV-induced encephalopathy, Kaposi's sarcoma, toxoplasmosis of the brain, pneumocystosis, cryptococcosis, aspergillosis.

The effect of treatment during this period depends on the timeliness of detection of atypically occurring tuberculosis and the appointment of adequate therapy. If tuberculosis is not detected in a timely manner, the process is generalized and treatment is ineffective.

Detection of tuberculosis in patients with HIV infection

It is recommended immediately after the diagnosis of HIV infection before the development of severe immunodeficiency, to identify patients who are at high risk of developing tuberculosis, for subsequent dynamic monitoring of them by a phthisiatrician who, in the late stages of HIV infection, when immunodeficiency develops, could promptly prescribe a preventive or basic course of treatment for tuberculosis.

To identify people at high risk of developing tuberculosis against the background of HIV infection, the following activities are carried out:

• all newly diagnosed patients with HIV infection must be examined by a phthisiatrician, noting a detailed history in the outpatient card regarding an increased risk of tuberculosis. The patient is informed about tuberculosis and measures for its prevention and is recommended that if symptoms characteristic of tuberculosis appear, he should immediately go to the phthisiatrician for an unscheduled examination and examination:
• immediately upon registration and then 1-2 times a year (depending on the risk of tuberculosis and the stage of HIV infection, radiation diagnostics of the chest organs are performed (an X-ray archive is created for the patient);
• when registering patients for HIV infection, a tuberculin test (2 TU) is performed, and then during the period of dynamic observation, it is placed 1-2 times a year (depending on the risk of tuberculosis and the stage of HIV infection with registration of results in the card dispensary observation.

During the period of dynamic monitoring of patients with HIV infection, if hyperergy, a turn or an increase in the reaction to tuberculin is detected, the phthisiatrician individually, taking into account the stages of HIV infection and objective data, decides on the appointment of anti-tuberculosis drugs to the patient.

At persons. that produce sputum, conduct its study for the presence of Mycobacterium tuberculosis. In the event of the appearance of clinical or laboratory manifestations of extrapulmonary tuberculosis, if possible, a bacteriological examination of the corresponding discharge and / or other indicated examination methods is carried out.

All patients with HIV infection from the risk group for tuberculosis who are hospitalized due to a deterioration in their general condition must be examined by a phthisiatrician.

Dispensary observation of patients suffering from HIV infection from a high-risk group of tuberculosis (but without clinical manifestations) is carried out by a phthisiatrician in the screening room at the AIDS center. The organization of such an office in an anti-tuberculosis institution will lead to the fact that patients with immunodeficiency will come to the focus of tuberculosis infection.

Patients with symptoms of tuberculosis are referred to the reference diagnostic room at the tuberculosis dispensary. The essence of the organization of such an office is the presence of a separate entrance to it. Thus, the intersection of epidemiologically dangerous for tuberculosis patients and patients with various genesis immunodeficiencies who come to the anti-tuberculosis dispensary for examination is minimized.

Screening for tuberculosis in patients with HIV infection

In the early stages of HIV infection, tuberculosis has a typical course, so screening during this period is carried out in the same way as in people without it.

Indications for extraordinary tuberculin diagnostics in children are given in Appendix D4 to the Order of the Ministry of Health of Russia dated March 21, 2003 M2 109 “On improving anti-tuberculosis measures in the Russian Federation”.

Under conditions of immunodeficiency beginning to develop in patients with HIV infection, the likelihood of developing tuberculosis increases, and therefore there is a need to increase the frequency of screening examinations and to introduce additional methods of examination for tuberculosis.

Formulation of the diagnosis for tuberculosis associated with HIV infection

When tuberculosis is detected in patients with HIV infection, a complete clinical diagnosis should include:

• stage of HIV infection;
• detailed diagnosis of tuberculosis and other secondary diseases. For example, if a patient with HIV infection in the stage of primary manifestations (it lasts a year from the onset of acute infection or seroconversion) develops tuberculosis due to a transient decrease in the immune status, then a diagnosis is made: HIV infection. stage of primary manifestations (PV).

This is followed by a detailed diagnosis of tuberculosis (in this case, the presence or absence of bacterial excretion is noted) and other secondary, and then concomitant diseases. The clinical classification of tuberculosis, used to formulate its diagnosis, is presented in the appendix to the Order of the Ministry of Health of Russia dated March 21, 2003 No. 109 "On the improvement of anti-tuberculosis measures in the Russian Federation."

If a patient with HIV infection, after completing the stage of primary manifestations and in the absence of any clinical symptoms indicating an insufficiency of the immune system (or laboratory manifestations of immunodeficiency), develops a limited tuberculosis process, it is inappropriate to consider it as a secondary disease. In such a case, the diagnosis indicates the latent stage of HIV infection.

Tuberculosis in patients with HIV infection, which developed after the completion of the stage of primary manifestations, indicates the stage of secondary diseases in the presence of one of the following factors:

• severe immunodeficiency, confirmed by laboratory methods (CD4
• dissemination of the tuberculosis process;
• a significant decrease in reactivity recorded during a morphological study of tissues involved in the tuberculosis process (for example, a lymph node).

Treatment of tuberculosis in patients with HIV infection

Treatment of tuberculosis in patients with HIV infection includes two directions.

• Organization of controlled treatment of tuberculosis in patients with HIV infection.
  • The diagnosis of tuberculosis in patients with HIV infection is confirmed by the phthisiatric CVCC, which includes a doctor who has specialized in HIV infection and who knows the features of the course of tuberculosis in the late stages of HIV infection.
  • Treatment of tuberculosis in patients with HIV infection is carried out in accordance with the standard regimens for tuberculosis therapy approved by the Russian Ministry of Health, but taking into account the specifics of the treatment of this pathology in patients with HIV infection.
  • During chemotherapy, medical staff monitors the intake of anti-tuberculosis and antiretroviral drugs by patients
  • After the completion of the main course of treatment for tuberculosis, dispensary observation of patients is continued by a phthisiatrician who specializes in HIV infection in order to prevent a relapse of the disease.
• Highly active antiretroviral therapy.
• Creation of a system of psychological and social adaptation of patients with tuberculosis, combined with HIV infection.
  • Carrying out planned and crisis counseling of patients, their relatives or close ones by a psychotherapist of the territorial AIDS center.
  • Before starting treatment, it is necessary to have a conversation with the patient, the purpose of which is to provide moral support to the patient, explain the difference between the early and late stages of HIV infection, convince him of the need for immediate long-term treatment in a specialized hospital, focus on continuing to live in the family, with relatives and friends. people, possible employment. The patient must be informed about the ways of transmission of both infections, measures for their prevention, rules for communicating with sexual partners. In the process of treatment of a patient with tuberculosis and HIV infection, it is necessary to constantly provide psychological support in order to fix the installation on strict adherence to the treatment regimen, refraining from taking drugs and alcohol.
  • Comprehensive advisory assistance of a social worker of the territorial AIDS center to patients, their relatives or friends on employment, housing, various benefits, etc.

The location of inpatient care for patients with tuberculosis associated with HIV infection depends on its stage and prevalence in the subject of the Russian Federation.

With a small number of cases of combined pathology in the subject of the Russian Federation, inpatient treatment of patients with tuberculosis in the stage of secondary diseases is carried out by an HIV infection specialist, but always with the advice of a highly qualified phthisiatrician. This is due to the fact that, in addition to the treatment of tuberculosis in these patients, treatment of HIV infection and the diagnosis and treatment of other secondary diseases are necessary. At the same time, all anti-epidemic measures against tuberculosis infection must be observed.

In the early stages of HIV infection (2,3,4A), these patients are treated by phthisiatricians with mandatory consultations of a specialist in HIV infection.

When HIV infection is detected for the first time in patients receiving inpatient treatment in a TB facility, an epidemiological investigation of the case of HIV infection is required. To do this, the center for the prevention and control of AIDS in the constituent entity of the Russian Federation, taking into account local conditions, should determine the procedure for its implementation in an anti-tuberculosis institution and the specialists responsible for the timeliness and quality of this work.

With a high need for the treatment of comorbidities in the subject of the Russian Federation, a specialized department is created, the staff of which includes phthisiatricians and infectious disease specialists.

Indications for antiretroviral therapy

Goals of highly active antiretroviral therapy (HAART):

• life extension;
• maintaining quality of life in patients with asymptomatic infection;
• improving the quality of life in patients with clinical manifestations of secondary diseases;
• prevention of development of secondary diseases;
• reducing the risk of HIV transmission.

When deciding on the appointment of HAART, the inadequate implementation of which is associated with the risk of developing drug-resistant strains of the virus, in addition to medical criteria, it is necessary to take into account socio-psychological ones, such as the patient's readiness and ability to undergo the prescribed treatment in full. If necessary, it is necessary to stimulate the patient's interest in therapy (counseling, psychosocial support, etc.). choose the most convenient regimen for taking medications. Before the appointment of HAART, the patient signs an informed consent.

The presence of HIV infection in itself is not an indication for HAART. Too early its appointment is impractical, and too late gives worse results.

Absolute readings;

• clinical: stages 2B, 2C or 4B, 4C in the progression phase;
• laboratory: CD4 count less than 0.2x10 9 /l. Relative readings:
• clinical: stage 4A (regardless of phase). 4B, 4C in remission;
• .laboratory: CD4 count equal to 0.2-0.35x10 9 /l, the level of HIV RNA (“viral load”) is more than 100 thousand copies per 1 ml.

In the presence of relative indications, some experts and guidelines recommend starting therapy, and some recommend continuing to monitor the patient until treatment is prescribed. In this situation, the Federal Scientific and Methodological Center for AIDS recommends. start treatment with the active desire of the patient and confidence in his good adherence to treatment, as well as if there are both clinical and laboratory relative indications for therapy.

The level of CD4-lymphocytes and HIV RNA is taken into account as indications for the appointment of HAART, if within a month before their assessment, the patient had no diseases accompanied by inflammatory processes and vaccinations.

If laboratory. indications for prescribing HAART were identified for the first time, and there are no clinical indications for the start of therapy, then repeated studies are needed to decide on treatment:

• with an interval of at least 4 weeks with a CD4 level of less than 0.2x10 9 /l;
• with an interval of at least 1.2 weeks with a CD4 count of 0.2-0.35x10 / l.

When prescribing HAART for clinical indications, it should be taken into account that people taking psychotropic drugs, fungal and bacterial lesions (lesions of the skin and mucous membranes, abscesses, cellulitis, pneumonia, endocarditis, sepsis, etc.) more often develop not as a result of HIV- infections, but as a manifestation of immunodeficiency associated. with drug use. In these cases, for the appointment of HAART, it is necessary to examine the number of CD4-lymphocytes.

It is recommended to start HAART in most patients with regimens containing, in addition to two drugs from the group of HIV nucleoside reverse transcriptase inhibitors. one drug from the group of non-nucleoside HIV reverse transcriptase inhibitors. However, if the patient has HIV infection in stage 4B (progression phase), the level of CD4 lymphocytes is less than 0.05x10 9 / l or the amount of HIV RNA is more than 1 million copies per 1 ml, it is recommended to start therapy with regimens containing one drug from the group of protease inhibitors HIV and two HIV nucleoside reverse transcriptase inhibitors.

First-line active antiretroviral therapy regimens

• efavirenz 0.6 g 1 time per day + zidovudine 0.3 g 2 times a day or 0.2 g 3 times a day + lamivudine 0.15 g 2 times a day.

For some patients, the standard HAART regimen cannot be prescribed (primarily due to the range of side effects of the drugs included in it), in particular:

• efavirenz is contraindicated in pregnant women and women planning (or not ruling out) pregnancy and childbirth while on antiretroviral therapy. This drug is not recommended for women of childbearing potential, who are not using barrier methods of contraception, or who work at night;
• zidovudine is not recommended for patients with anemia and granulocytopenia If the hemoglobin level is less than 80 g / l, stavudine can be included in the HAART regimen instead of zidovudine.

If absolute or relative contraindications to any of the drugs recommended for the standard regimen are identified, changes are made to it.

If the patient has an alanine aminotransferase level corresponding to the 2nd degree of toxicity or more, it is recommended to use HAART regimens with HIV protease inhibitors.

Alternative first-line HAART regimen:

• lopinavir + ritonavir 0.133/0.033 g 3 capsules 2 times a day + zidovudine 0.3 g 2 times or 0.2 g 3 times a day + lamivudine 0.15 g 2 times a day.

• nelfinavir 1.25 g 2 times a day + zidovudine 03 g 2 times a day or 0.2 g 3 times a day + lamivudine 0.15 g 2 times a day.

The frequency of laboratory tests to assess the efficacy and safety of HAART:

• the level of HIV RNA and the number of CD4-lymphocytes - 1 and 3 months after the start of HAART, then 1 time in 3 months;
• clinical blood test - after 2 weeks. 1 month, 3 months after the start of HAART, then 1 time in 3 months;
• biochemical blood test - 1 and 3 months after the start of HAART, then 1 time in 3 months;
• in the presence of chronic viral hepatitis - the first study of ALT 2 weeks after the start of HAART.

Features of highly active antiretroviral therapy in patients with tuberculosis

Some experts recommend postponing HAART until the completion of anti-TB drugs: in this case, the patient's management is simplified, both infections are treated according to standard schemes, and the side effects of the drugs do not increase. However, in patients with low CD4 counts, delaying initiation of HAART can lead to new complications of HIV infection and even death. Therefore, for TB patients with a very high risk of HIV infection progression (with CD4-lymphocyte count less than 0.2 10 9 /l or generalization of the TB process), it is recommended not to postpone the start of HAART.

Adverse events with the use of anti-tuberculosis drugs, as a rule, develop in the first 2 months of treatment. In this regard, it is recommended to start HAART between 2 weeks and 2 months after the start of anti-TB treatment. depending on the number of CD4 lymphocytes.

Patients with tuberculosis should be given the main recommended or alternative HAART regimen.

Alternatives to efavirenz may include saquinavir/ritonavir (400/400 mg twice daily or 1600/200 mg once daily), lopinavir/ritonavir (400/100 mg twice daily) and abacavir (300 mg twice daily) .

Instead of efavirenz, if there are no other alternatives, nevirapine (200 mg once a day for 2 weeks, then 200 mg 2 times a day) can also be used in the following regimens: stavudine + lamivudine + nevirapine or zidovudine + lamivudine + nevirapine.

Metabolism of HIV protease inhibitors

Rifamycins (rifabutin and rifampicin) induce the activity of enzymes of the cytochrome P450 system that metabolize non-nucleoside reverse transcriptase inhibitors and HIV protease inhibitors, and therefore reduce the serum concentrations of these antiretroviral drugs. In turn, these two groups of antiretroviral drugs increase the serum concentrations of rifabutin and rifampicin through the same mechanism. Thus, drug interactions can lead to ineffectiveness of antiretrovirals and increased toxicity of anti-tuberculosis drugs. The anti-TB drug rifabutin can be used with all HIV protease inhibitors (with the exception of saquinavir) and with all non-nucleoside HIV reverse transcriptase inhibitors. if the dose is adjusted periodically.

Tuberculosis and motherhood

Pregnancy and childbirth are accompanied by a restructuring of the functions of the endocrine system, changes in immunity, metabolism and are risk factors for tuberculosis. The incidence of pregnant women and puerperas is 1.5-2 times higher than the overall incidence of tuberculosis in women. Tuberculosis can develop during any period of pregnancy, but more often in the first 6 months after childbirth, tuberculosis that occurs in women during pregnancy and in the postpartum period is usually more severe than detected before pregnancy.

Tuberculosis first occurring during pregnancy

In women who become ill with tuberculosis during pregnancy, various forms of pulmonary tuberculosis are found.

In young previously uninfected women who have undergone primary infection with Mycobacterium tuberculosis, primary tuberculosis is often detected.

Reactivation of endogenous tuberculosis infection occurs more often. In this case, disseminated tuberculosis or various forms of secondary tuberculosis are diagnosed. A severe course of the disease with severe tuberculosis intoxication can adversely affect the development of the fetus and lead to spontaneous miscarriage.

In the first trimester of pregnancy, the initial manifestations of tuberculosis, caused by moderately severe intoxication (weakness, malaise, loss of appetite, weight loss), are often associated with toxicosis of pregnancy. In the second half of pregnancy, tuberculosis, despite pronounced morphological changes in the lungs, also often occurs without pronounced clinical symptoms, which greatly complicates its detection.

The development of tuberculosis during pregnancy may be associated with HIV infection. In these cases, tuberculous lesions are found not only in the lungs, but also in other organs.

Impact of pregnancy on tuberculosis

Exacerbation of tuberculosis during pregnancy does not develop in all women. Tuberculosis is rarely activated in the phases of compaction and calcification, and vice versa, there is a sharp increase or progression in the phases of the active process. Particularly severe outbreaks occur in patients with fibrous-cavernous tuberculosis. The most dangerous for exacerbation of tuberculosis is the first half of pregnancy and the postpartum period. Outbreaks in the postpartum period are especially malignant.

The impact of tuberculosis on the course of pregnancy and childbirth

In severe destructive or disseminated forms of tuberculosis, as a result of intoxication and oxygen deficiency, toxicosis of the first and second halves of pregnancy often develops, and premature birth occurs more often. In newborns, physiological weight loss is more pronounced and its recovery is slower. The timely appointment of specific therapy allows you to bring the pregnancy to a successful birth, to avoid exacerbations of the postpartum period.

Diagnosis of tuberculosis in HIV infection

Tuberculosis in pregnant women is detected during examination of complaints of weakness, fatigue, excessive sweating, loss of appetite, weight loss, subfebrile temperature, as well as cough - dry or with sputum, shortness of breath, chest pain. If such complaints appear, the obstetrician-gynecologist of the antenatal clinic should refer the patient to an anti-tuberculosis dispensary. The dispensary conducts a Mantoux test with 2 TEs of PPD-L, performs clinical blood and urine tests. In the presence of sputum, it is examined for Mycobacterium tuberculosis by bacterioscopic and bacteriological methods, additionally using PCR.

An X-ray examination during pregnancy is performed in difficult diagnostic situations as an exception, protecting the fetus with a lead shield or apron.

If tuberculosis is suspected or the diagnosis is confirmed, family members of the pregnant woman are examined.

Management of pregnancy in a patient with tuberculosis

In most cases, tuberculosis is not a reason for artificial termination of pregnancy. Comprehensive anti-tuberculosis therapy often allows pregnancy to be maintained without compromising the health of the mother and child. Pregnancy is usually maintained in patients with active pulmonary tuberculosis without destruction and bacterial excretion, with tuberculous pleurisy, as well as in women who previously underwent surgery for pulmonary tuberculosis without complications.

Indications for termination of pregnancy in patients with tuberculosis are as follows:

• progressive course of newly diagnosed pulmonary tuberculosis, tuberculous meningitis, miliary tuberculosis:
• fibrous-cavernous, disseminated or cirrhotic pulmonary tuberculosis:
• pulmonary tuberculosis in combination with diabetes mellitus, chronic diseases of other systems and organs with severe functional disorders (pulmonary-cardiac, cardiovascular, renal failure);
• tuberculosis of the lungs, which requires surgical intervention.

Termination of pregnancy should be with the consent of the woman during the first 12 weeks. During the period of preparation and after termination of pregnancy, it is necessary to strengthen anti-tuberculosis therapy. Re-pregnancy is recommended not earlier than in 2-3 years.

Pregnant women with an established diagnosis of tuberculosis are registered and are under the supervision of a district phthisiatrician and an obstetrician-gynecologist. If progressive tuberculoma, cavernous or fibrous-cavernous tuberculosis with bacterial excretion is detected in a pregnant woman, the possibility of surgical intervention on the lung in order to quickly stop bacterial excretion is not ruled out.

For childbirth, a woman with tuberculosis is sent to a special maternity hospital. If such a maternity hospital does not exist. an obstetrician-gynecologist and a phthisiatrician should notify the maternity ward in advance in order to carry out organizational measures that exclude contact of the patient with healthy women in labor. Childbirth in patients with active tuberculosis is often more difficult than in healthy women, with more blood loss and other complications. In case of pulmonary tuberculosis with pulmonary heart failure, in the presence of artificial pneumothorax, it is advisable to have an operative delivery by caesarean section.

Intrauterine infection of the fetus with Mycobacterium tuberculosis is rare, the mechanisms of such infection are hematogenous through the umbilical vein or aspiration of infected amniotic fluid. After birth, the contact of a child with a mother with tuberculosis in terms of primary infection with Mycobacterium tuberculosis and tuberculosis disease is very dangerous.

Management of newborns with tuberculosis and HIV infection

Management of a child born to a mother with tuberculosis:

• If a pregnant woman is sick with active tuberculosis, regardless of the isolation of Mycobacterium tuberculosis, the following measures are taken:
  • doctors of the maternity ward are notified in advance about the presence of tuberculosis in a woman in labor;
  • the woman in labor is placed in a separate box;
  • immediately after the birth of the child is isolated from the mother;
  • transfer the child to artificial feeding;
  • the child is vaccinated with BCG;
  • the child is separated from the mother for the period of immunity formation - for at least 8 weeks (the child is discharged home to relatives or placed in a specialized department according to indications);
  • if there are contraindications to vaccination or if it is impossible to separate the child, chemoprophylaxis is carried out;
  • before discharge, an examination of the future environment of the child is carried out;
  • before discharge, all premises are disinfected;
  • mother is hospitalized for treatment.
• If the child was in contact with the mother before the introduction of the BCG vaccine (birth of a child outside a medical facility, etc.). carry out the following activities:
  • the mother is hospitalized for treatment, the child is isolated from the mother,
  • tuberculosis vaccination is not carried out,
  • the child is prescribed a course of chemoprophylaxis for 3 months;
  • after chemoprophylaxis, a Mantoux reaction is carried out with 2 TU;
  • with a negative Mantoux reaction with 2 TEs, BCG-M is vaccinated;
  • after vaccination, the child remains separated from the mother for at least 8 weeks.
• If the tuberculosis dispensary was not aware of the presence of tuberculosis in the mother and the detection of tuberculosis occurred after the introduction of the BCG vaccine to the child, the following measures are taken:
  • the child is separated from the mother;
  • the child is prescribed prophylactic treatment, regardless of the timing of the introduction of the BCG vaccine;
  • such children are under close supervision in the TB dispensary as the most threatened risk group for TB.

1-2 days after childbirth, a puerperal undergoes an X-ray examination of the lungs and, taking into account bacteriological data, determines further tactics regarding the possibilities of breastfeeding and the necessary treatment.

Breastfeeding of newborns is allowed only to mothers with inactive tuberculosis who do not excrete mycobacterium tuberculosis. The mother at this time should not take anti-tuberculosis drugs, so as not to affect the formation of immunity after vaccination of the child with BCG.

Treatment of tuberculosis in pregnant women with HIV infection

Treatment of tuberculosis in pregnant women, as well as in nursing mothers, is carried out in accordance with standard chemotherapy regimens and individualization of treatment tactics. When choosing drugs, you need to consider:

• possible adverse reactions to aminosalicylic acid and ethionamide in the form of dyspeptic disorders, so they should not be prescribed for toxicosis of pregnancy;
• the embryotoxic effect of streptomycin and kanamycin, which can cause deafness in children whose mothers were treated with these drugs;
• possible teratogenic effect of ethambutol, ethionamide.

The least dangerous for the pregnant woman and the fetus is isoniazid. It should be prescribed for therapeutic purposes and for the prevention of exacerbations of tuberculosis.

It's important to know!

At present, due to the increase in the resistance of the human body to tuberculosis, the widespread use of specific vaccination and revaccination of BCG, the timely diagnosis of primary infection with tuberculosis in childhood and adolescence, hematogenous disseminated tuberculosis is rare.

To date, tuberculosis and HIV are among the most common diseases among the population that require mandatory therapy. This will help improve the quality of life, and in the first case - completely recover. Therefore, everyone should know the main signs of these diseases in order to timely diagnose and begin to eliminate them.

HIV and tuberculosis together proceed in a rather aggressive form, since against the background of immunodeficiency there is a rapid development of complications from almost all internal organs. In this case, there are a number of features that we will consider further.

If a patient has a malignant course of tuberculosis, HIV (AIDS) is necessarily suspected by a doctor and appropriate tests are carried out to confirm it. At the same time, AIDS patients are considered as possible carriers of mycobacteria.

Tuberculosis in HIV-infected people can proceed according to the following options:

• Tuberculosis and HIV infection entered the body at the same time.
• The pathology of the lungs arose against the background of an already existing immunodeficiency.
• The immunodeficiency virus entered the body, infected with mycobacteria earlier.

Patients falling into the first category are at the greatest risk, since their illnesses proceed rapidly and can lead to irreparable conditions in a short period of time.

In order to prevent the development of serious conditions, one should consider whether tuberculosis can be cured with HIV infection, as well as the main signs of these pathologies.

Reasons for the development of tuberculosis on the background of HIV

The immunodeficiency virus enters the body through infected biological fluids, it can be blood, semen, and particles of the infectious agent are also found in the urine, breast milk of the patient.

Although tuberculosis and AIDS have completely different routes of infection, they can be contracted at the same time. And all because the first is transmitted by airborne droplets, and in order for mycobacterium to enter the body, it is not necessary to have sexual intercourse or use one needle, as is often the case with drug addicts. It is enough just to be in close contact with a source of pulmonary tuberculosis. With HIV, it will undoubtedly begin to multiply immediately and provoke the onset of the corresponding symptoms, because due to reduced immunity, the body is not able to cope with the pathogen.

Forms of tuberculosis in combination with HIV infection

The disease against the background of immunodeficiency can occur in the following forms:

• Latent. In this case, mycobacteria multiply in the body of an infected person, but there are no pronounced symptoms from the internal organs. This form is common.
• Active. This course of tuberculosis in HIV-infected people is much more common. In this case, the rapid multiplication of mycobacteria occurs, pronounced symptoms of the pathology are observed. Pathogens are released into the external environment, which increases the risk of spread to others.

With AIDS, this disease quickly passes from a latent to an active form. The reason for this may be the following factors:

• The patient's age is over 65 years or children under 5.
• Unbalanced nutrition.
• Pregnancy.
• The presence of bad habits, in particular, drug addiction, alcoholism.

In the latter case, tuberculosis, HIV and hepatitis often occur together, since it occurs not only due to reduced immunity, but also against the background of systemic toxic effects on hepatocytes of alcohol and drugs.

Clinical picture

Symptoms and signs of tuberculosis in HIV in most cases do not differ from the typical course of this disease in patients who do not suffer from immunodeficiency. However, their severity is determined by the degree of neglect of the process and periods of infection.

With pulmonary tuberculosis and HIV, the clinic depends on the sequence of infection with these diseases. The first occurs in a malignant form if it develops in an organism suffering from immunodeficiency. The less stable cellular immunity, the more pronounced the signs of the disease and the more unfavorable the prognosis.

• As a rule, the following symptoms are observed:
• Fever, excessive sweating, especially at night.
• Weakness, decreased performance.
• Cough that does not go away for more than 21 days and does not respond to traditional methods.
• Violation of the digestive system.
• Cachexia (severe weight loss). Patients lose about 10-20 kg, usually at least 10% of the body weight that was before the onset of the disease.
• In advanced cases, hemoptysis is observed.
• Chest pain.

In addition to lung damage, tuberculosis of the lymph nodes can be observed in HIV-infected people. At the same time, they become quite dense, it is difficult to displace them at least a few millimeters during palpation. To the touch, bumpy, enlarged in size.

HIV, tuberculosis and hepatitis C can also develop simultaneously, since the first affects not only the lungs, but also any other internal organs. Among them are the liver, spleen, nails, skin, bones, genitals. The production of antibodies to HIV in extrapulmonary tuberculosis occurs in exactly the same way.

How does tuberculosis progress in HIV-infected children?

The child often becomes infected with these diseases from the mother during the process of gestation or during childbirth. This is possible if a woman was ill before pregnancy or became infected after her onset.

Babies born to HIV-infected mothers must be separated immediately after birth to reduce the chance of infection, if not already. HIV and tuberculosis in children proceed with approximately the same symptoms, but it is very difficult for an immature organism to fight pathogens. At the same time, there is a decrease in body weight and it is restored for a long time.

If the baby has not been in contact with the mother, BCG vaccination is carried out. When it is impossible to do it, a prophylactic course of chemotherapy is prescribed. The same applies to children who have been in contact with an infected mother. In this case, BCG is contraindicated.

If the baby has been in contact with a sick mother, then he is shown a dispensary observation, since the risk of developing a disease caused by mycobacteria is quite high.

Diagnosis of tuberculosis in HIV-infected people

It is possible to identify pathology in immunodeficiency with the help of standard studies that are used in such cases. As a rule, use:

• History taking: the duration of the symptoms, its severity, the presence of contact with the source of infection are clarified.
• Objective examination. Allows you to determine the localization of pain, the state of the lymph nodes.
• Clinical examination of blood, urine. Used to detect traces of pathogens.
• X-ray of the chest organs. Shows the localization of the pathological process, allows for differential diagnosis with other diseases with similar symptoms.
• Sputum microscopy, seeding on a nutrient medium. It is used to establish the type of pathogen and its resistance to certain groups of drugs.
• ELISA. Allows you to determine antigens and antibodies to pathology.

A biopsy of certain organs, such as the liver, spleen, lymph nodes, and skin, may also be prescribed. This is carried out in cases when it comes to an extrapulmonary form of pathology.

Sometimes some of the above tests need to be done multiple times. This is explained by the fact that in the secondary form of AIDS, a false negative result is possible. This is also possible in the initial stage of the disease, when the symptoms are not expressed, and the antibodies have not yet had time to develop and spread throughout the body.

In addition, all patients with HIV should undergo regular screening examinations, which consist of chest x-rays. This will help to identify the pathology at an early stage and timely treat tuberculosis and HIV infection.

Methods of treatment of tuberculosis in HIV-infected people

Therapeutic measures are prescribed to patients immediately after confirmation of the diagnosis. It is worth being prepared for the fact that they will take a fairly long period, which lasts at least six months. However, with an aggressive course, as happens against the background of immunodeficiency, the treatment of HIV-patients with tuberculosis can take up to 2 years.

Direct treatment of HIV and tuberculosis involves taking anti-tuberculosis drugs and antiretroviral therapy. The first includes such medicines:

• Isoniazid, streptomycin. Drugs are prescribed at any stage of treatment.
• Rifampicin, parasinamide. Used as the main anti-tuberculosis therapy for HIV after 2 months of using the above medications.

In HIV, tuberculosis chemoprophylaxis, as well as its treatment, is carried out mainly with rifampicin and rifabutin. For best results, in most cases, these drugs are prescribed at the same time. The dosage should be determined only by a doctor, since they have a lot of reactions and have contraindications.

HIV-associated tuberculosis also requires antiretroviral therapy, the only way to fully cope with the pathology. It is carried out for the following purposes:

• Improving the quality of life, as well as its extension.
• Reducing the chance of spreading the virus.
• Reducing the risk of secondary manifestations of tuberculosis, AIDS and cancer, which often develops against the background of these two diseases.

Therapy for AIDS and tuberculosis of the lungs or other organs involves the use of a huge number of toxic drugs. To reduce the likelihood of complications, you should eat right, take medication after meals.

Chemoprophylaxis of tuberculosis in HIV-infected people allows you to completely recover from the disease, despite reduced immunity.

In addition to taking medication, disinfection against HIV tuberculosis is carried out in the house where the patient lives, which will help prevent infection of other family members, as well as the development of relapse.

Prognosis for tuberculosis and HIV

Many patients are interested in the question of life expectancy with tuberculosis and HIV infection. It depends on many factors, primarily on the neglect of the pathology and the presence of secondary lesions of the internal organs, which can be seen in the photo. The prognosis for HIV and pulmonary tuberculosis depends on the level of CD4, the lower they are, the sooner the death will occur.

It should be noted that in the terminal stage of AIDS, any therapy does not bring the desired result.

With pulmonary tuberculosis and HIV, disability is issued based on the results of studies if they show that the patient has completely lost vital functions and cannot take care of himself.

Prevention of tuberculosis in HIV-infected people

It is worth remembering that the prevention of tuberculosis in HIV should be in the first place for every patient. It provides for timely BCG vaccination, this is relevant for children. However, if the baby has already become infected with immunodeficiency, such manipulation is contraindicated, as this can provoke the development of secondary pathologies.

It is also necessary to observe the rules of personal hygiene, be sure to wash your hands thoroughly after visiting public places. It is there that it is often possible to pick up mycobacteria.

If a person already has AIDS, it is important to stay on antiretroviral therapy and strictly follow the doctor's instructions to reduce the chance of contracting various infections.

Tuberculosis and AIDS, the prevention of which is not so difficult, often occur together, thereby complicating the condition of patients. To prevent this from happening, it is recommended not to neglect the advice of doctors and use all prescribed medications, because against the background of a weakened immune system, any infection can become fatal.

Tuberculosis in HIV-infected patients is malignant, tends to generalize and progress due to severe immunodeficiency.

Identification of a patient with widespread and progressive tuberculosis serves as a signal for the need for a targeted examination of him for HIV infection. At the same time, AIDS patients should be considered as potential TB patients.

The HIV epidemic has brought and continues to make radical changes in the epidemiology of tuberculosis. The main impact of HIV infection is expressed in the rate of progression of clinically significant tuberculosis in persons previously infected with MBT.

Tuberculosis and HIV infection can be combined in three ways:

1. primary infection with tuberculosis of HIV-infected patients;
2. simultaneous infection with HIV infection and tuberculosis;
3. the development of the tuberculous process against the background of the development of immunodeficiency in HIV infection (AIDS).

Individuals infected with both TB and HIV are at particularly high risk of the disease. They have an annual probability of developing tuberculosis is 10%, while for the rest of the population, this probability does not exceed 5% throughout life.

In countries with a high HIV infection rate, more than 40% of TB patients are also HIV-infected. Due to the growing AIDS epidemic, epidemiological forecasts are very unfavorable.

An epidemiological analysis of the data shows that the main route of transmission of HIV infection in Russia is parenteral, which occurs in the vast majority of cases through the administration of drugs (96.8% of cases of the established routes of transmission).

Among the other high-risk groups of the disease (patients with sexually transmitted infections, people with a homosexual orientation), the percentage of detected cases of HIV infection is much lower, but in recent years there has been an increase in the incidence of sexual transmission.

The source of HIV infection is an HIV-infected person at all stages of the disease. The most likely transmission of HIV is from a person at the end of the incubation period, at the time of the initial manifestations and in the late stage of infection, when the concentration of the virus reaches a maximum, but the virus in the blood is little neutralized by antibodies. Susceptibility to HIV in humans is universal.

Almost all biological fluids of an HIV-infected person (blood, semen, vaginal and cervical secretions, urine, CSF and pleural fluid, breast milk) contain viral particles in varying concentrations. However, the greatest epidemiological risk of HIV transmission is blood and seminal fluid.

Pathogenesis and pathomorphology. The factors explaining the regularity of the predominant combination of tuberculosis and HIV infection are the peculiarities of the mechanisms of pathogenesis of both diseases.

HIV infection significantly affects the state of immunoreactivity in tuberculosis, changing the relationship in the system of cellular immunity, disrupting the differentiation of macrophages and the formation of specific granulation tissue.

Accordingly, a more frequent development of tuberculosis in HIV-infected people can occur both due to a decrease in resistance to primary or re-infection with MBT (exogenous infection), and as a result of reactivation of old residual post-tuberculosis changes, weakening of anti-tuberculosis immunity (endogenous reactivation).

Histomorphological manifestations of tuberculous inflammation in HIV infection also show a clear correlation with the number of CD4+ cells in the blood. As their level falls, the following changes can be traced in the zone of tuberculous inflammation: the number decreases, and then the typical tuberculous granulomas completely disappear, they lack the characteristic Pirogov-Langhans cells. This significantly reduces the number of epithelioid cells; the number of macrophages may increase, but the inferiority of their function is expressed in the inability to form granulomas.

The tissue reaction is manifested mainly by cheesy necrosis with a large number of MBT with very mild exudative-proliferative processes. This is largely due to an increase in TNF-a expression. With the development of tuberculosis in an HIV-infected patient, as a result of an increased release of this lymphokine, a necrotic process develops in the lungs.

The presence of typical necrosis is characteristic of the terminal period of AIDS in tuberculosis. Affected tissues quickly undergo massive liquefaction and are literally “stuffed” with MBT. In the late stages of HIV infection, active tuberculous process is the main cause of death in almost 90% of cases. In this case, as a rule, hematogenous generalization of tuberculosis with pulmonary and extrapulmonary metastases takes place, therefore, some authors tend to consider the detection of combined pulmonary and extrapulmonary localizations of tuberculosis as one of the signs of AIDS.

There are frequent cases of combined development of tuberculosis and other AIDS-indicative diseases (pneumocystis pneumonia, toxoplasmosis, cytomegalovirus infection, Kaposi's sarcoma).

clinical picture. The severity of the clinical manifestations of the tuberculous process is the greater, the smaller the number of CD4+ cells circulating in the peripheral blood. With an unfavorable prognosis for life in individuals with comorbidities, the immunogram shows a sharp decrease in the number of CD4+ lymphocytes, B-lymphocytes and natural killers, an increase in the concentration of IgG, M, A, a sharp increase in circulating immune complexes and a decrease in the functional activity of neutrophils. In such cases, the progression of tuberculosis against the background of chemotherapy in 30% of cases leads to death.

The main clinical manifestations of tuberculosis against the background of HIV infection are asthenia, persistent or intermittent fever, prolonged cough, significant weight loss, diarrhea, swollen lymph nodes (mainly cervical and axillary, less often inguinal), dense, bumpy, poorly displaced on palpation. The severity of tuberculosis symptoms in HIV-infected and AIDS patients largely depends on the degree of inhibition of cellular immunity.

The disease often proceeds as an infiltrative or generalized process. The most typical complaints are weakness, cough, high fever and sweating. Characterized by a significant weight loss of the patient, weight loss is 10-20 kg and is always more than 10% of the original.

More pronounced clinical symptoms are observed in patients who developed tuberculosis on the background of HIV infection than in patients with tuberculosis who later became infected with HIV and developed AIDS.

Manifestations of tuberculosis, when the number of lymphocytes is still quite high, may be the most typical and do not differ in any way from the clinical and radiological picture in HIV-negative patients.

At this stage, the usual manifestations of predominantly pulmonary tuberculosis dominate in patients. Upper lobe infiltrative and less often focal processes develop, in half of the cases with decay, therefore, specific therapy is effective, and tuberculosis is cured. As the number of CD4+ lymphocytes in the blood decreases (to 200 per 1 mm3 or less), along with pulmonary lesions (or instead of them), extrapulmonary localizations of tuberculosis are increasingly detected.

The features of the clinical symptoms of tuberculosis in these cases are an increased frequency of extrapulmonary and disseminated lesions; negative skin reactions to tuberculin as a manifestation of anergy, atypical changes on chest radiographs, and the relative rarity of cavitation.

Clinical manifestations of tuberculosis are often atypical. When the lungs are affected, lobar infiltrates radiologically do not have a typical localization, often the process is prone to dissemination (miliary tuberculosis).

Especially often, the lymph nodes and meningeal membranes, as well as the pleura, are involved in the pathological process. In many patients, tuberculin sensitivity is reduced, with the frequency of negative reactions inversely proportional to the level of CD4+ lymphocytes.

Recently, there are more and more reports of the predominance of extrapulmonary localization of tuberculosis in HIV-infected individuals. In this case, it is possible to develop a specific process in the cervical, mesenteric, less often tonsillar lymph nodes, as well as in the muscles of the chest and abdominal cavity and the brain with the development of specific abscesses and leaks. Often this leads to the death of the patient, despite the specific and surgical treatment.

With AIDS, a deep damage to the immune system is detected when the content of CD4 + lymphocytes is less than 200-100 per 1 mm3, which indicates a decrease in T-cell immunity up to its disappearance. The most severe, acutely progressive and widespread processes develop, such as miliary tuberculosis and meningitis.

Tuberculous changes in the lungs in AIDS patients are characterized by a more frequent development of hilar adenopathy, miliary rashes, the presence of predominantly interstitial changes and the formation of pleural effusion. At the same time, their upper parts of the lungs are significantly less frequently affected, and the caverns and atelectasis characteristic of tuberculosis are not so often formed.

Often in patients with AIDS, instead of miliary rashes on radiographs of the lungs, diffuse merging infiltrative changes are found, proceeding according to the type of caseous pneumonia. A much more frequent development of tuberculous mycobacteremia is considered very characteristic, which in AIDS patients is complicated by septic shock with dysfunction of many organs.

Diagnosis of tuberculosis in HIV-infected persons is carried out on the basis of standard methods of mandatory clinical examination, consisting of:

• study of complaints and anamnesis of the patient;
• objective examination;
• blood and urine tests;
• chest x-ray;
• triple microscopic examination of sputum and its sowing on nutrient media;
• evaluation of intracutaneous Mantoux reaction with 2 TU PPD-L;
• ELISA of anti-tuberculosis antibodies and tuberculosis antigens.

Difficulties in diagnosing tuberculosis arise mainly in the stage
secondary manifestations, including AIDS. The predominance of disseminated and extrapulmonary forms during this period with a sharp decrease in the number of cases of lung tissue decay significantly reduces the number of patients in whom MBT is detected in sputum during microscopy (according to the Ziehl-Nelsen method) and during sowing.

However, it must be taken into account that during this period of the course of HIV infection and AIDS, mycobacteremia is determined in almost all patients, and the detection of the pathogen in the peripheral blood is the most important diagnostic test.

Given the high frequency of extrapulmonary lesions in patients with tuberculosis and AIDS, an important role in the diagnosis is played by biopsies of the lymph nodes, spleen, liver, bone marrow and other organs, where acid-fast mycobacteria can be detected in biopsy specimens in more than 70% of patients.

In the pathoanatomical study of biopsy specimens, signs of a decrease in the reactivity of the organism are often determined, which manifests itself in an extremely weak formation of granulomas with a predominance of necrosis, and in more than half of the cases, granulomas characteristic of tuberculosis are absent.

Study of tuberculin sensitivity according to the Mantoux test with
2 TE PPD-L and ELISA for the determination of anti-tuberculosis antibodies and MBT antigens have limited diagnostic value due to immunosuppression and anergy to tuberculin in patients with tuberculosis and AIDS.

Frequent extrapulmonary localization in patients with tuberculosis and AIDS suggests widespread use in the diagnosis of unclear cases of computed tomography.

Treatment. Chemotherapy for respiratory tuberculosis in HIV-infected patients is highly effective. A common aspect of the treatment of patients with tuberculosis and AIDS is the simultaneous administration of several antiretroviral drugs (nucleoside and non-nucleoside reverse transcriptase inhibitors and viral protease inhibitors).

Currently, the appointment of antiretroviral drugs is becoming a necessary element in the treatment of tuberculosis with advanced forms of infection.

• tuberculosis patients with a CD4+ lymphocyte count of more than 350/mm3 usually do not need antiretroviral therapy and receive only chemotherapy;
• tuberculosis patients with a CD4+ lymphocyte count of 350 to 200 per mm3 are prescribed antiretroviral therapy at the end of the intensive phase of chemotherapy, 2-3 months after the start of treatment;
• TB patients with a CD4+ lymphocyte count of less than 200/mm3 are prescribed antiretroviral therapy concomitantly with chemotherapy.

Chemotherapy for tuberculosis in HIV-infected and AIDS patients, in principle, is no different from the treatment regimens for HIV-negative patients and is carried out according to general rules.

HIV-infected patients with newly diagnosed pulmonary tuberculosis in the intensive phase of chemotherapy for 2-3 months receive four main anti-tuberculosis drugs: isoniazid, rifampicin, pyrazinamide and ethambutol.

It should be noted that antiretroviral drugs such as protease inhibitors are inactivated by an enzyme whose activity is increased by rifampicin. In this regard, it is more expedient to use rifabutin, a synthetic analogue of rifampicin, in chemotherapy regimens.

A number of antiretroviral drugs (Zerit, Videx, Chivid) in combination with isoniazid mutually enhance neurotoxicity, therefore, in chemotherapy regimens, it is better to use phenazid, a drug from the ginkgo group that does not have neurotoxicity.

If MBT drug resistance is detected, chemotherapy is corrected and the terms of the intensive phase of treatment are extended. It is possible to combine the main ones, to which the sensitivity of the MBT has been preserved, and reserve drugs, however, the combination should consist of five drugs, of which at least two should be reserve.

The indication for the continuation phase of treatment is the cessation of bacterial excretion by sputum microscopy and positive clinical and radiological dynamics of the process in the lungs. The continuation phase of treatment lasts 4-6 months with isoniazid and rifampicin or isoniazid and ethambutol.

The total duration of treatment is determined by the timing of the cessation of bacterial excretion and stabilization of the process in the lungs. Due to the risk of low efficiency of the combination of reserve drugs, as well as recurrence of tuberculosis caused by multi-resistant MBT strains, chemotherapy is carried out for at least 18-22 months. At the same time, it is very important to provide long-term treatment of such patients with reserve anti-tuberculosis drugs.

Tuberculosis in HIV-infected patients is malignant with numerous complications. That is why, when tuberculosis is detected, the patient urgently needs to be tested for HIV infection.

1. HIV appears before tuberculosis infection. Quite often it happens that the patient is not aware of HIV until he develops tuberculosis. The fact is that many people neglect the annual outpatient examination and therefore they simply cannot diagnose a positive HIV status.
2. The occurrence of ailments at the same time.

Symptoms

As medical practice shows, carriers of a dual disease complain of the same symptoms as patients infected only with tuberculosis infection. It is important to understand that the signs of the manifestation of the disease depend on the degree of development of the disease, as well as on the period of stay of the infection in the body.

List of the most common factors indicating an infection:

1. Lethargy, drowsiness, lack of concentration, poor performance.
2. Unsatisfactory work of the gastrointestinal tract (diarrhea, diarrhea, constipation, and so on).
3. Coughing. Expectoration of sputum with blood.
4. Fever and seizures.
5. Heat.
6. Violation of the heart rhythm.
7. Unreasonable sharp decrease in body weight.
8. Severe pain in the sternum: burning; sharp, pulling, pressing, wave, aching pain.

It is also worth paying attention to the lymph nodes, since HIV-infected patients often experience negative side effects and complications associated with them. Lymph nodes increase significantly, it is difficult to feel them on palpation, since touching causes acute pain, it occurs.

If at least two regularly observed symptoms are found, it is worth immediately consulting a doctor, since there is a high probability of a lung infection. The lack of timely diagnosis and treatment poses a danger not only to an infected person, but also to all people with whom he comes into contact.

Survey

Medical workers adhere to one correct scheme: if a person is diagnosed with HIV infection, he is prescribed an examination for tuberculosis infection. The same is true in the opposite case: if a person has tuberculosis, he is immediately sent for an HIV test. Such tests are carried out to exclude all the negative circumstances that may accompany both ailments.

Action plan for receiving positive HIV tests.

1. Informing the patient about the high probability of contracting tuberculosis. A visual examination by a specialist in the field without a full medical examination.
2. The patient must be registered with a phthisiatrician without fail.
3. Every six months, the chest is diagnosed using ultrasonography.
4. The patient monitors the dynamics of his physical condition every day. If any symptoms suggestive of infection with tuberculosis appear, he should seek expert advice.
5. If the general condition of a person has deteriorated significantly in a short period, immediate hospitalization in a specialized hospital is required.

Prevention of tuberculosis in HIV-infected people is simply necessary, because the life expectancy of the patient directly depends on it.

Classification

At the moment, two main forms have been identified: latent and active (open).

1. The first form is the most common. With it, pathogenic bacteria are present in the human body, but do not cause the development of the disease.
2. With the open type, the development of tuberculosis occurs as actively as possible. All symptoms appear quickly enough, the general condition of the body deteriorates sharply. Bacteria multiply and become more dangerous every day.

In people suffering from HIV and tuberculosis, the possibility of an active type of disease increases tenfold. There is also a list of side factors that can worsen the situation:

• pregnancy or breastfeeding;
• lack of vitamins;
• age up to fourteen years or after seventy;
• deadly habits (drug addiction or alcoholism).

Treatment

It is important to understand that pulmonary tuberculosis and HIV are not a sentence. If you turn to a doctor, then at any stage of the disease he will be able to prescribe the right course of drug exposure, which can improve the general condition of the patient.

The main thing - no self-treatment. Do not use traditional medicine, especially without consulting a doctor. So you can only hurt yourself.

If tuberculosis is detected against the background of HIV infection, the doctor prescribes drugs such as Rifabutin and Rifampicin. They are allowed to be taken at the same time. If the patient has an individual intolerance to the components, then the doctor can replace them with drugs with an analog effect.

A further treatment plan is selected for each specific case. It completely depends on the condition of the patient, the stage of development of the disease and other side factors. Do not rely on the fact that there is a universal method of treatment.

To cure one of the presented diseases does not mean to get rid of it forever. Often the prognosis is not encouraging, as relapses are possible. Therefore, after the course of treatment, it is necessary to strictly observe the constructed rehabilitation plan. Otherwise, you will lose all positive results in the fight against infection.

Prevention of tuberculosis of the lungs and lymph nodes in HIV infection is also an important aspect. There are several stages of preventive action. After a recovery period, patients undergo a course of chemoprophylactic procedures, and in the future, all measures to prevent re-infection will be reduced to a visit to a phthisiatrician.