A rapid and low-cost microscopic observation drug susceptibility assay for detecting TB and MDR-TB among individuals infected by HIV in South India.

Background: The converging epidemics of HIV and tuberculosis (TB) pose one of the greatest public health challenges of our time. Rapid diagnosis of TB is essential in view of its infectious nature, high burden of cases, and emergence of drug resistance. Objective: The purpose of this present study was to evaluate the feasibility of implementing the microscopic observation drug susceptibility (MODS) assay, a novel assay for the diagnosis of TB and multi-drug-resistant tuberculosis (MDR-TB) directly from sputum specimens, in the Indian setting. Materials and Methods: This study involved a cross-sectional, blinded assessment of the MODS assay on 1036 suspected cases of pulmonary TB in HIV-positive and HIV-negative patients against the radiometric method, BD-BACTEC TB 460 system. Results: Overall, the sensitivity, specificity, positive predictive value, and negative predictive value of the MODS assay in detecting MTB among TB suspected patients were 89.1%, 99.1%, 94.2%, 95.8%, respectively. In addition, in the diagnosis of drug-resistant TB, the MODS assay was 84.2% sensitive for those specimens reporting MDR, 87% sensitivity for those specimens reporting INH mono-resistance, and 100% sensitive for specimens reporting RIF mono-resistance. The median time to detection of TB in the MODS assay versus BACTEC was 9 versus 21 days (P < 0.001). Conclusion: Costing 5 to 10 times lesser than the automated culture methods, the MODS assay has the potential clinical utility as a simple and rapid method. It could be effectively used as an alternative method for diagnosing TB and detection of MDR-TB in a timely and affordable way in resource-limited settings.

Post-HAART tuberculosis in adult patients with HIV in India; Incidence, Clinical and Immunological profile.

Bacground: Highly Active Antiretroviral Therapy (HAART) was introduced in National AIDS Control Programme in 2004 to reduce the morbidity and mortality among those affected with HIV/AIDS. Tuberculosis, being an important coinfection, its emergence / occurrence in post-HAART period has potential implications. Objective:: Primary objectives were to study the incidence of post- HAART tuberculosis in HIV patients and to identify the possible risk factors. It was also intended to understand the clinical and immunological profile of this important condition. Methodology: Eligible adults and adolescents with HIV disease enrolled on HAART at Government Hospital of Thoracic Medicine, Tambaram Sanatorium, Chennai, from April, 2004 to March, 2007, formed the study population. They were monitored and screened for the occurrence of tuberculosis after commencing HAART. Clinical details and immunological profile of these patients were analysed. Results: Two hundred and sixty-two patients (5.1%) of 5099 patients followed-up for one to four years were found to have Post HAART TB with 100-person year risk of 2.83. Post HAART TB occurred predominantly in men (67.6%) and in 31- 44 years age group (69.8%) with 100-person year risk being 3.26 and 2.83 respectively. Pulmonary, Extra-pulmonary and disseminated tuberculosis were found to occur in the frequencies of 78%, 16% and 6% respectively. A total of 144 patients (54.9%) developed tuberculosis within six months and this number increased to 202 (77%) by 12 months. 230 patients (87.7%) had base level CD4 cell count < 200 / mm3. Conclusion: Tuberculosis was found to occur pre-dominantly in adult male patients with HIV during the first year after the initiation of HAART. Significantly, occurrence of Post HAART TB remained almost the same (5%) among patients treated for TB prior to the initiation of HAART.

Effectiveness of Management of HIV-TB Patients Under Programme Conditions in India.

HIV patients, on antiretroviral therapy (ART), with co-existing tuberculosis patients were assesed for clinical and immunological progress at GHTM ART centre for effectiveness of management programme. Six hundred and twenty two HIV-TB patients are placed under both Anti-TB Treatment (DOTS) and ART. While 337 patients are continuing their ATT, details of the remaining 283 patients are provided. 214 patients (76%) completed their treatment successfully. 29 patients (10%) expired before completing treatment for TB and 40 patients (14%) were treatment defaulters. Immunologicallly CD4 cells registered significant increase from 101(mean) to 306 (mean) in 202 treatment-completed patients (p=.001). Linking HIV patients on ART to their nearest DOTS centres for treating tuberculosis is feasible. High Mortality, even before completing the prescribed course of ATT is attributable to low immunity and complicating opportunistic infections. Referral and linkage services shall be improved and strengthened for enhanced treatment adherence.

Prevalence of acquired MDR-TB and HIV co-infection.

BACKGROUND: Mounting prevalence of primary and acquired multidrug-resistant tuberculosis in India is a sorry reminder of all round failure in our fight against tuberculosis and also of the necessity for new effective strategies. OBJECTIVES: (1) To assess the prevalence and pattern of drug resistant pulmonary tuberculosis among treated patients or on those on treatment without adequate response and (2) to evaluate HIV seropositivity among MDR-TB patients. METHODS: Pulmonary TB patients, who had at least six months of unsuccessful anti-tuberculous treatment were selected for the study. Their sputum specimens were examined for M. tuberculosis culture and drug sensitivity pattern and serological examinations for HIV infection were carried out. RESULTS: Sputum specimens of 618 patients' (61.8%) of a total of 1000 examined had shown culturable M. tuberculosis. Four hundred ninty-five patients (49.5%) were found to expectorate tubercle bacilli resistant to one or more anti TB drugs. MDR-TB was detected in 339 patients (33.9%). HIV seropositivity among MDR-TB was 4.42%. Significantly, 245 patients (24.5%) had tubercle bacilli resistant to one or more reserve drugs too (ethionamide, kanamycin and/or ofloxacin). CONCLUSIONS: Prevalence of MDR-TB was high in the study population. It is essentially an acquired condition. Its association with HIV disease was at present on the lower side, an observation contrary to published western literature. Higher rates of resistance for reserve drugs (ethionamide, kanamycin and/or ofloxacin) in patients who never had these drugs in their earlier treatment schedules suggest the possibility of emerging spontaneous drug resistant mutants.

Angiographic correlates of anterior ST segment depression in acute inferior wall myocardial infarction.

This study was conducted prospectively to assess the correlation between the pattern of anterior ST segment depression on the admission electrocardiogram and the in-hospital morbidity and mortality in patients with acute inferior wall myocardial infarction. Coronary angiography was also done to assess its correlation, if any, with pattern of anterior ST segment depression. Our study cohort comprised of 165 consecutive patients with acute inferior wall myocardial infarction divided into four groups based on admission electrocardiogram. Group I (n = 33): patients with no anterior ST segment depression; group II (n = 16): patients with ST segment depression in leads V1-V3; group III (n = 71): patients with ST segment depression in leads V4-V6, I and aVF, and; group IV (n = 45): patients with ST segment depression in all anterior leads (V1-V6, I, aVL). The outcomes were analysed in terms of high grade atrioventricular block, Killip class II or higher failure, and in-hospital mortality. Coronary angiography was performed to analyse coronary anatomy. Group IV patients had increased incidence of complete heart block (37.8% vs 15.2% in the total group) (p < 0.001) and increased mortality (11.1% vs 4.2% in the total group) (p < 0.05). This group also had greater incidence of triple vessel disease (76.7%) (p < 0.001). Group II patients had greater incidence of double vessel disease (88.9%) (p < 0.05) and had no triple vessel disease. Group III patients had double vessel disease (76.5%) (p < 0.05) or triple vessel disease (23.5%) (p = NS) and no single vessel disease. Coronary angiography in group II showed greater incidence of involvement of left circumflex artery and right coronary artery while in group III there was left anterior descending artery and right coronary artery disease. We conclude that patients with anterior ST segment depression in group III and group IV categories are in high risk subset with acute inferior wall myocardial infarction.