LIP

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TB CASE STUDIES OF M TUBERCULOSIS IN HIV INFECTED
CHILDREN Helena Rabie
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C-K
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• 15 Month infant presented with
• Stridor and lower airways infection
• Features of fetal alcohol syndrome
• Clinical GORD
• HIV infection confirmed with DNA-PCR
• CD4- 1762 cells CD8 2964 cells
• PPD skin test negative
• Social concern

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Actions

• Miliary tuberculosis suspected and treatment
  initiated 4 drugs
• Repeated episodes of drug rash thought to be
  related to pyrizinamide
• Treated with 4 drugs

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After 6 months of treatment

• Wt 7.2 Kg
• Clinically stable
• Attended TB clinic but missed hospital
  appointments

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Investigations

• 8 Gastric Washings for TB
• Ear discharge culture
• Bone marrow aspirate and culture
• CD4 846 cells CD8 4754 cells
• Viral Load gt3Mil copies (gtLog 6)
• PPD skin test negative
• CT-SCAN

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LUNG BIOPSY
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Follicular Broncholitis
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What happened?

• TB treatment stopped (6/12 completed)
• HAART to be initiated as outpatient

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• 46 days after biopsy M Tuberculosis confirmed on
  culture
• Started on prior drugs
• 6 Weeks later
• Resistance testing
• Resistant Isoniazid Rifampicin
• Sensitive Ethambutol
• MDR treatment started

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Weight chart
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S-X
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• 4 Yr old girl referred from district hospital
• Treated for TB _at_ 3 Yr at local clinic
• Now Weight 10 kg
• TB again ?Culture positive
• 4 Drugs (Rif, INH, PZA, Ethambutol)
• Weight 10 kg
• Repeated episodes of pneumonia and septicemia
• Features of chronic lung disease

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What happened

• HAART Stavudine Lamivudine Efavirenz
• In hospital TB treatment for 9 months

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TB-cultures after 9 months

• M Tuberculosis,
• Drug sensitive to all tested medication
• Decide to treat for at least 6 months after last
  positive culture (still on treatment)

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Measured response
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B-B
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• 9 Years
• Previous PTB at age 6, treated for 6 months with
  3 drugs (HIV status not known then)
• Stavudine, lamivudine efavirenz for the past 5
  months CD4 350 cells _at_ initiation

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• Weight loss and abdominal pain
• Ultra sound abdomen showed large glands,
  confirmed with CT-scan
• Sputum negative culture
• CD4 813 cells Viral load below detectable
• Presumptive diagnosis of extra-pulmonary TB
• 5 Drugs Rif, INH, PZA, Ethambutol, Ethionamide

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• cxr

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• Readmission with abdominal pain and symptoms
  suggestive of gastritis
• Weight has increased
• Managed symptomatically
• Repeat US and CT-Scan
• Symptoms improved in hospital and discharged with
  antacid

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Readmission again

• Severe abdominal pain and anorexia
• Lost 2 Kg
• Respiratory distress
• Vomiting blood
• Renal failure
• high creatine
• no proteinuria

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On some further prompting

• B-B Takes ART very well
• Mom finds TB pills hidden in bed room
• B-B admits not taking medication
• Mom admits that she does not observe treatment
• MDR suspected

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• Biopsy of abdominal glands
• Bone marrow aspirate
• Renal biopsy
• CXR

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Disseminated Tuberculosis

• M Tuberculosis cultured
• Resistant to INH and Rif
• Added Amikasin, Ofloxacin, terizidone

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• Gain 5Kg but still persistent abdominal pain
• Follow-up ultrasound shows psoas abscess
• Drained (MDR cultures 2 months after treatment
  started)

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Now

• Weight 15 kg more than before MDR treatment
  initiated
• Mom did not access care ?Died of TB

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Lessons learned

• TB difficult to diagnose in HIV infected children
• The diagnosis is often made over time
• Despite extensive investigation you can still be
  wrong
• TB hard to treat
• TB and HIV share adherence and social issues

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Questions

• How can we improve diagnosis?
• What is the optimal duration for treatment?
• What is the role of HAART?
• Measuring response to HAART?