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Unmasked Tuberculosis-Immune Reconstruction Disease by Pelvic Inflammatory in HIV-Infected Women From an Urban TB Burden Area: Case Series FREE TO VIEW

Valerios Kortzis, MS; Georgios Athanasiou, MS; Ioan Arghir, MS; Elena Dantes, PhD; Simona Cambrea, PhD; Paraschiva Postolache, PhD; Oana Arghir, PhD
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Faculty of Medicine Ovidius University, Constanta, Romania

Chest. 2014;145(3_MeetingAbstracts):87A. doi:10.1378/chest.1825532
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SESSION TITLE: Tuberculosis Case Report Posters

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: The potential complications of immune reconstitution disease during antiretroviral therapy (ART) are extremely diverse and included the unmasking form of tuberculosis. TB caused by immune reconstruction inflammatory syndrome is associated with a high mortality risk although HIV-infected patients are treated with antiretroviral agents.

CASE PRESENTATION: We report 2 cases diagnosed in 2011 with unmasked TB and obvious extra pulmonary manifestations in HIV- infected women. Routine investigation included chest radiograph and CT scan, laboratory tests. Case 1- A 45 year- old white woman, smoker 20 pack yrs, co infected HIV- TB since 2009, was admitted in our clinic in March 2011. ART was initiated 4 months ago. Laboratory tests revealed negative smears for acid fast bacilli. Prolonged fever for more than 1 week and persistent abdominal pains were determined by an ovarian abscess with peritonitis revealed by CT scan. TB meningitis was diagnosed 3 weeks later and directly observed therapy (DOT) with anti tuberculosis drugs was initiated. Case 2- A 31 year old white woman with known HIV infection since 2009, was admitted to our clinic with pulmonary shadows, cough, fever, nausea and vomiting, moderate anemia and acute abdominal pain with a progressive illness after 2 months of ART. A left tubo ovarian abscess was diagnosed and, after surgical intervention recommended. The patient was readmitted to our clinic 17 days later for persistent cough, fever, night sweats and worsening shortness of breath. A new chest X-ray revealed bronchopneumonia and bacteriological exam of sputum revealed positive cultures for Mycobacterium tuberculosis. Both cases survived after DOT was ended.

DISCUSSION: In TB burden area, patients with HIV and TB co-infection who are antiretroviral treated should be routinely screened for TB disease. Manifestations of TB disease could be subtle or atypical. A high index of suspicion needs to be maintained in cases with hyper-inflammatory features that might be truly be considered life-threatening as in our case series were the very painful ovarian abscesses.

CONCLUSIONS: Described unmasked and accelerated worsening of TB disease post-ART suggest that immune reconstitution inflammatory syndrome had contributed in both cases. Because pelvic inflammation disease is considered co-epidemic with HIV, the diagnosis of TB was delayed, the progression of TB disease was fast and severe, but the prognosis was finally a favorable one.

Reference #1: Lawn SD, Meintjes G. Pathogenesis and prevention of immune reconstitution disease during antiretroviral therapy. Expert Rev. Anti Infect. Ther. 9(4), 415-430 (2011)

Reference #2: Lawn SD, Wilkinson RJ, Lipman MC, Wood R. Immune reconstitution and unmasking tuberculosis during antiretroviral therapy. Am.J. respir. Crit. Care Med. 177, 680-685 (2008)

DISCLOSURE: The following authors have nothing to disclose: Valerios Kortzis, Georgios Athanasiou, Ioan Arghir, Elena Dantes, Simona Cambrea, Paraschiva Postolache, Oana Arghir

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