AETIOLOGY AND PRESENTATION OF HIV/AIDS-ASSOCIATED PULMONARY INFECTIONS IN PATIENTS PRESENTING FOR BRONCHOSCOPY AT A REFERRAL HOSPITAL IN NORTHERN TANZANIA

ABSTRACTObjectives: To determine the aetiological agents of pulmonary infections in HIV-infected Tanzaniansand to correlate the causative agents with clinical, radiographic features, and mortality.Design: A prospective study.Setting: Kilimanjaro Christian Medical Centre (KCMC), Tanzania.Subjects: Bronchoalveolar lavage fl uid (BAL) were obtained from 120 HIV infected patients withpulmonary infections. BAL for causative agents was analysed and correlated with clinical andradiographic features, and one-month outcome.Results: Causative agents were identifi ed in 71 patients (59.2%) and in 16 of these patients, multipleagents were found. Common bacteria were identifi ed in 35 patients (29.2%), Mycobacteriumtuberculosis in 28 (23.3%), Human Herpes Virus 8 (HHV8) in 12 (10%), Pneumocystis jiroveci in nine(7.5%) and fungi in fi ve (4.2%) patients. Median CD4 T cell count of the patients with identifi edcauses was 47 cells/μl (IQR 14-91) and in the 49 patients with undetermined aetiology was 100 cells/μl (IQR 36-188; p=0.01). Micronodular chest radiographic lesions were associated with presenceof M. tuberculosis (p=0.002). The one-month mortality was 20 (16.7%). The highest mortality wasassociated with HHV8 (41 .7%) and M. tuberculosis (32.1%). Mortality in patients with undeterminedaetiology was 11.3%. No death occurred in patients with PCP.September 2007 EA S T AF R I C A N ME D I C A L JOURNAL 421INTRODUCTIONSub-Saharan Africa is the region of the world mostaffected by HIV/AIDS, more than 70% of HIVinfected individuals live in this African sub-continent,(1) and the HIV pandemic is still increasing. Despitethis, data pertaining to the disease presentation fromthis region compared to the developed world areinsuffi cient and require regular updating. The clinicalpresentation of HIV/AIDS and the occurrence ofopportunistic infections depend on different factorssuch as the presence of endemic diseases, qualityof health services, availability of and access to antiretroviraltreatment, and levels of education of thepopulation. Pulmonary infections are the leadingcauses of morbidity and mortality in HIV-infectedindividuals (2,3). A microbiological diagnosis is ofcrucial importance in HIV infected patients withpulmonary infections because of atypical clinicaland radiographic manifestations and high mortality(4). Because in these settings resources are limited,treatment is largely empirical, but to be effective,it should be tailored to locally prevailing causativeorganisms. Therefore health facilities equipped withadvanced diagnostic techniques should monitor thetrend of diseases and obtain data on aetiologicalpathogens, so that empirical treatment regimenscan be improved.The aim of this study was to fi nd the aetiologicalpathogens of pulmonary infections in HIV/AIDSpatients who presented with features of pulmonaryinfection for bronchoscopy.Furthermore, we correlated the pathogensidentified with clinical and radiographicpresentations, level of immunity, and outcomeafter one month.MATERIALS AND METHODSAt Kilimanjaro Christian Medical Center (KCMC)in northern Tanzania we enrolled 120 HIV infectedpatients aged 18 years and above, who presentedwith features of chest infection such as cough(dry or productive) and/or chest pain, dyspnoea,fever and chest radiographic abnormalities. Thesepatients were recruited at the endoscopy unitwhere bronchoscopic procedures are done. Thepatients were referred by their attending cliniciansfor bronchoscopy as part of patient’s managementafter failing to establish the causative agent by othermethods and/or following failure to respond toempirical treatment. Pregnant women and patientswith oxygen saturation less than 90% under 61/mmof oxygen were excluded from the study.Bronchoscopy and bronchoalveolar lavage (BAL)was performed by standard procedure using fl exiblefi beroptic bronchoscope. Briefl y, the bronchoscopewas wedged in one of the heavily involved segmentalbronchi as seen on the chest radiograph. In case ofdiffuse lung involvement, the scope was wedgedin one of the segmental bronchi of the right middlelobe. Then aliquots of 50 ml or less of sterile saline atbody temperature, up to a maximum of 150 ml, wereinstilled and at least 40 ml was sucked back into asterile container. The sediments of BAL fl uid obtainedby centrifugation at 1500 g for 10 minutes were usedfor laboratory tests to identify the aetiological agentof the chest infection.For identifi cation of M. tuberculosis, BAL sampleswere decontaminated with 4% NaOH, centrifugedand cultured using in-house made Lowenstein-Jensen (LJ) solid medium, with a maximum of eightweeks incubation. Diagnosis of M. tuberculosis wasbased on positive culture results showing acid fastbacilli (AFB) in ZN stain.Diagnosis of pneumocystis pneumonia (PCP)was based on identification of Pneumocystis (P)jiroveci with at least one of the following techniques:Giemsa stain, Gomori methenamine silver (GMS)stain or immunofl uorescence test (IFT). Also realtime PCR was performed for detection of P. jiroveciDNA in the BAL fl uid, using 40 as the cycle threshold(CT) cut off value (5).Conventional PCR was used for the diagnosis ofHuman herpes virus 8 (HHV8) as described by Changand collaborators (6).Fungi were diagnosed by direct smear andculture for seven days using Sabouraud dextroseConclusion: In this population of severely immunosuppressed HIV-infected patients withpulmonary infection a variety of causative agents was identifi ed. Micronodular radiographiclesions were indicative of TB. High mortality was associated with M. tuberculosis or HHV8. Nodeath occurred in patients with P. jiroveci infection

Aetiology and presentation of HIV/AIDS-associated pulmonary infections in patients presenting for bronchoscopy at a referral hospital in northern Tanzania.

OBJECTIVES: To determine the aetiological agents of pulmonary infections in HIV-infected Tanzanians and to correlate the causative agents with clinical, radiographic features, and mortality. DESIGN: A prospective study. SETTING: Kilimanjaro Christian Medical Centre (KCMC), Tanzania. SUBJECTS: Bronchoalveolar lavage fluid (BAL) were obtained from 120 HIV infected patients with pulmonary infections. BAL for causative agents was analysed and correlated with clinical and radiographic features, and one-month outcome. RESULTS: Causative agents were identified in 71 (59.2%) patients and in 16 of these patients, multiple agents were found. Common bacteria were identified in 35 (29.2%) patients, Mycobacterium tuberculosis in 28 (23.3%), Human Herpes Virus 8 (HHV8) in 12 (10%), Pneumocystis jiroveci in nine (7.5%) and fungi in five (4.2%) patients. Median CD4 T cell count of the patients with identified causes was 47 cells/microl (IQR 14-91) and in the 49 patients with undetermined aetiology was 100 cells/ microl (IQR 36-188; p = 0.01). Micronodular chest radiographic lesions were associated with presence of M. tuberculosis (p = 0.002). The one-month mortality was 20 (16.7%). The highest mortality was associated with HHV8 (41.7%) and M. tuberculosis (32.1%). Mortality in patients with undetermined aetiology was 11.3%. No death occurred in patients with PCP. CONCLUSION: In this population of severely immunosuppressed HIV-infected patients with pulmonary infection a variety of causative agents was identified. Micronodular radiographic lesions were indicative of TB. High mortality was associated with M. tuberculosis or HHV8. No death occurred in patients with P. jiroveci infection

Aetiology and presentation of HIV/AIDS-associated pulmonary infection in patients presenting for bronchoscopy at a referral hospital in nothern Tanzania

No Abstract. East African Medical Journal Vol. 84 (9) 2007: pp. 420-42

Verbundprojekt zur Entwicklung und Anwendung gentechnologischer Methoden in der Genomforschung der Pflanzen. Isolierung von Resistenzgenen der Gerste und ihre Transformation: Neue Konzepte fuer die Pflanzenzuechtung Schlussbericht

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