TUBERCULOSIS IN PATIENTS CO-INFECTED WITH VISCERAL LEISHMANIASIS AND HIV – A NEW DIAGNOSTIC AND MANAGEMENT CHALLENGE

Abstract

Intro: Between 6-10% of adults with Visceral Leishmaniasis (VL) are co-infected with HIV in Bihar, India. Although it is well known that VL-HIV patients commonly present with advanced HIV disease, there is minimal evidence on the prevalence of tuberculosis (TB) in these patients and no evidence on how best to diagnose and manage this triad. Methods: A total of 150 patients with VL and HIV were enrolled in a study investigating AmBisome therapy alone and a combination of AmBisome and Miltefosine. For the first time in the literature, all patients were screened for TB through a combination of chest X-Ray, Cartridge Based Nucleic Acid Amplification Testing (CBNAAT), and Abdominal Ultrasound. Patients were treated initially for VL, then commenced antitubercular therapy (ATT) between days 7-14 depending on the clinical condition, followed by Antiretroviral therapy (ART) two weeks after ATT. Findings: A total of 19% (n=28) of patients were co-infected with TB. 25 cases were pulmonary TB, and 3 had Extra pulmonary TB. Five patients were on ATT at enrolment. Seven cases of immune reconstitution inflammatory syndrome (IRIS) associated TB were reported in the study, of which 4 died. The majority (n=5) were unmasking TB. Symptoms predictive of IRIS appeared to be refractory pyrexia more than 10 days after VL treatment initiation and enlarged abdominal necrotic lymph nodes on enrolment ultrasound. Incidence of IRIS reduced with increasing the gap between ATT and ART initiation from two to three weeks for those who were ART naïve, and improved early diagnosis. Case fatality rate of TB-VL-HIV patients was 17.9%(n=5), compared to 1.6% (n=2) in VL-HIV patients (p<0.01). Conclusion: VL-HIV patients should all be screened for TB using CBNAAT. The results suggest that VL treatment results in substantial IRIS that may require delayed initiation of ART, while severe IRIS-associated TB remains a major risk in this cohort of patients.