BA.5 sub-lineages associated with higher severity of COVID-19 infection: A cross-sectional study in Indonesia.

Objectives: We aimed to compare the clinical severity and outcome among laboratory-confirmed Omicron variant cases admitted between January and December 2022. Methods: This is a cross-sectional study conducted in Hasan Sadikin General Hospital between January and December 2022. We enrolled patients aged ≥18 years with laboratory-confirmed Omicron infection. Data were collected from clinical records and a whole genome sequencing database. We compared the risk of severe symptoms and mortality using a logistic regression analysis adjusted for sex, age, comorbidities, and vaccination status. Results: We enrolled 255 patients and the main sub-lineages were BA.1 (16.1%), BA.2 (11.4%), BA.5 (35.7%), XBB (22.7%), and BQ.1 (14.1%). Compared with BA.1/BA.2, BA.5 sub-lineages were associated with severe symptoms (adjusted odds ratio of 2.9, 95% confidence interval 1.1-8.2, P <0.05). The highest risk of severe symptoms and mortality was linked with a high number of comorbidities (adjusted odds ratio of 7.8, 95% confidence interval 1.7-22.4, P <0.05). Booster vaccination was protective of severity and mortality. Conclusions: Disease severity was associated with BA.5 sub-lineages and multiple comorbidities. Good management is particularly important for people with comorbidities. Furthermore, booster vaccination is also required to reduce severity and mortality.

Risk Factors Associated with Unsuppressed Viral Load in People Living with HIV Receiving Antiretroviral Treatment in Jawa Barat, Indonesia.

Introduction: The success rate of antiretroviral therapy (ART) was sufficiently high globally that by 2030, Human Immunodeficiency Virus (HIV) infection would no longer become a significant health issue. The evaluation of the success rate of ART in Indonesia is still fairly low, with estimates that 6.1% of the total population living with HIV. This is affected by treatment failure and limitations of viral load (VL) testing. We investigated the risk factors for failure of VL suppression in HIV patients on ART. Methods: An institution-based cross-sectional study was conducted among 1203 subjects, medical records of adult HIV patients in Jawa Barat, who followed the Viral Load Months Program from the government in 2020. Data were taken using total sampling technique and analyzed with multivariate logistic regression model using SPSS version 21 software. Results: Of the 1203 subjects, 5.2% had unsuppressed VL and 94.8% had suppressed VL. The results showed that a nevirapine-based regimen was the main factor increasing unsuppressed risk (Prevalence Odds Ratio (POR) 3.75 (95% CI: 1.41-9.99, p-value 0.008)). The other factors are ART duration <5 years (POR 2.46; 95% CI: 1.22-4.97, p-value 0.012), WHO clinical stage III-IV (POR 2.30; 95% CI: 1.30-4.08, p-value 0.004), and loss to follow-up history (POR 2.28, 95% CI: 1.03-5.07). Meanwhile, the zidovudine-based regimen reduced the risk of failure (POR 0.34 (95% CI: 0.12-0.96)). Conclusion: Several factors could contribute to unsuppressed VL in HIV patients receiving ART, which warrants further investigations.

Generalized Reddish Skin Nodules.

Diagnosis of nodular red lesions is challenging. The differential diagnosis includes dermal nevus, angioma, pyogenic granuloma, amelanotic melanoma, eccrine poroma, Kaposi's sarcoma, skin malignancy or metastasis. Erythema nodosum is one of the common consideration of the red skin nodules, however fully work up should be done to find the right diagnosis.A 60 years old female admitted to our hospital due to pain dark reddish skin nodules since one month. She had continuously high grade fever of 39 Celsius accompanied by arthralgia and fatigue since two months prior to admission and she lost 6 kg of weight in 2 months. On admission, physical examination revealed slight fever, pale conjunctiva, mild hepatosplenomegaly, tender dark red nodules 0.3 to 2 cm, firm edge, at her cheek, abdominal area and both lower extremities. No lymph nodes enlargement was noticed. Her laboratory test showed haemoglobin 9,1 g/dl, WBC 3,040/mL, PLT 149,000/mL, SGOT 48 U/L, SGPT 43 U/L, urea 12.5 mg/dL, creatinine 0.67 mg/dL. She was found to be non-reactive for HBsAg, HCV, and HIV antigens. Urine routine and microscopic examination was unremarkable.Her histopathology of left foot nodule biopsy revealed cutaneous lymphoma. The immunohistochemical (IHC) stain of CD45, CD20, and CD10 were positive, Ki67 were also positive  with >70% tumor cells, while CD3,CD56, CD30, and Granzyme were negative. Her final diagnosed was Cutaneous Diffuse large B cell lymphoma.Primary cutaneous lymphomas of B-cells occur less frequently than primary cutaneous T-cells lymphomas. Primary extra-nodal diffuse large B-Cell lymphoma (DLBCL) can be seen in up to 40% of cases. However skin involvement is less common and in a large cohort of DLBCL cases, skin involvement at presentation was seen only in 3.3% of cases.It characterized by few lesions, in general showing nodules or infiltrations of relatively fast growth and have no itching. The diagnosis is made by the immunohistochemical findings, clinicopathological correlation, and molecular pathology.  The lymphomas have different clinical behaviours despite being identical in morphological appearance. The primary lymphomas presents with local recurrence in up to 68% of the cases and with rare extra-cutaneous dissemination, with an average rate of 5-year survival varying from 89 to 96%. Cutaneous lymphoma should be always become one of considered diagnosed of skin red nodules even it is rare.

The effect of diabetes mellitus on COVID-19 mortality among patients in a tertiary-level hospital in Bandung, Indonesia.

Immune system dysregulation in people with diabetes mellitus (DM) increases the risk of acquiring severe infection. We compared the clinical characteristics and laboratory parameters of coronavirus disease 2019 (COVID-19) patients with and without DM and estimated the effect of DM on mortality among COVID-19 patients. A retrospective cohort study collecting patients' demographic, clinical characteristics, laboratory parameters and treatment outcomes from medical records was conducted in a hospital in Bandung City from March to December 2020. Univariable and multivariable logistic regression was performed to determine the association between DM and death. A total of 664 COVID-19 patients with positive real-time reverse transcription polymerase chain reaction for severe acute respiratory syndrome coronavirus 2 were included in this study, of whom 147 were with DM. Half of DM patients presented HbA1c ≥10%. DM patients were more likely to present with comorbidities and severe to critical conditions at admission (P <0.001). Laboratory parameters such as neutrophil-lymphocyte count ratio, C-reactive protein, D-dimer, ferritin, and lactate dehydrogenase were higher in the DM group. In the univariate analysis, variables associated with death were COVID-19 severity at baseline, neurologic disease, DM, age ≥60 years, hypertension, cardiovascular disease, and chronic kidney disease. DM remained associated with death (aOR 1.82; 95% CI 1.13-2.93) after adjustment with sex, age, hypertension, cardiovascular disease, and chronic kidney disease. In conclusion, COVID-19 patients with DM are more likely to present with a very high HbA1c, comorbidities, and severe-critical illness. Chronic inflammation in DM patients may be aggravated by the disruption of immune response caused by COVID-19, leading to worse laboratory results and poor outcomes.

Antibodies against Histoplasma capsulatum and Aspergillus fumigatus among chronic TB patients in Indonesia: a cross-sectional study.

Chronic pulmonary fungal infections may occur in patients with previous history of pulmonary tuberculosis (TB), and are often clinically misclassified as TB, especially when bacteriological confirmation for Mycobacterium tuberculosis is absent. In this study, we investigated the prevalence of antibody against Histoplasma capsulatum and Aspergillus fumigatus in patients with confirmed and clinically chronic TB. Antibodies against H. capsulatum and A. fumigatus were measured from serum samples using enzyme-linked immunosorbent assay (ELISA). The presence M. tuberculosis in sputum was confirmed using smear microscopy, GeneXpert MTB/RIF assay, or culture. Antibodies against H. capsulatum and A. fumigatus were elevated in 16.9% and 26.9% of bacteriologically confirmed chronic TB patients, and 12.1% and 18.2% in those without bacteriological confirmation, respectively. Approximately one-third of patients who had positive anti-Histoplasma antibody also had elevated levels of antibody against Aspergillus fumigatus (P < .001). Our study highlights the importance of chronic pulmonary fungal infection in post-TB patients with recurrent respiratory symptoms.

This study describes the presence of antibodies against Aspergillus fumigatus and Histoplasma capsulatum in patient with pulmonary TB patients. Our study highlights the importance of chronic pulmonary fungal infections in post-TB patients with recurrent respiratory symptoms.

Clinical and treatment factors associated with the mortality of COVID-19 patients admitted to a referral hospital in Indonesia.

Background: Indonesia had the second-highest number of COVID-19 cases and deaths in South-East Asia. We aimed to determine the factors associated with this mortality and the effect of the recommended COVID-19 treatment regimen during the first 10 months of the epidemic. Methods: This was a retrospective cohort study using secondary data from medical records. In total, 689 adult COVID-19 inpatients hospitalized between March and December 2020 were enrolled. Clinical characteristics, laboratory parameters, and treatments were analyzed by survival outcome. Kaplan-Meier statistics were used to estimate survival. Findings: Of the 689 patients enrolled, 103 (14.9%) died. Disease severity was highly associated with mortality (hazard ratio [HR]: 7.69, p < 0.001). Other clinical factors associated with mortality were older age and comorbidities. Based on laboratory parameters, higher procalcitonin and C-reactive protein contents and a neutrophil-to-lymphocyte ratio >3.53 were also linked to mortality. Favipiravir was associated with lower mortality, with adjusted HRs of 0.24 (0.11-0.54) and 0.40 (0.17-0.98) among the mild/moderate and severe cases, respectively. Among patients with severe disease, steroids showed some beneficial effects in the early days of hospitalization. Interpretation: Older age and comorbidities were associated with disease severity and, consequently, higher mortality. Higher mortality after the second week of hospitalization may be related to secondary bacterial infection. Favipiravir showed significant benefit for COVID-19 survival, while steroids showed benefit only in the early days of admission among patients with severe disease. Funding: This research did not receive a specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Antibiotic Resistance in COVID-19 with Bacterial Infection: Laboratory-Based Surveillance Study at Single Tertiary Hospital in Indonesia.

Purpose: Coronavirus disease 2019 (COVID-19) is a new pandemic affecting the respiratory system and caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In addition to the increased use of antibiotics, the length of stay of hospitalized patients affects the risk of bacterial infections among the COVID-19 patients. However, this pandemic has interrupted antibiotic surveillance activity and led to an information gap about the prevalence and characteristics of bacterial infection. This study aims to describe the antibiotic resistance in COVID-19 patients with culture-proven bacterial infection using a laboratory-based surveillance approach. Patients and Methods: A retrospective study with a cross-sectional design was conducted on adult patients that confirmed positive for COVID-19 according to the International Classification of Diseases 10th Revision (ICD-10). From March 2020 to October 2021, data were obtained from the hospital information system and merged with the culture and antibiotic susceptibility test from laboratory information system at Hasan Sadikin General Hospital. The outcome is the prevalence percentage of resistance to selected antibiotics in patients with COVID-19. The resistance percentage is considered high when equal to or more than 20%. Results: There was 2786 adult patient confirmed for COVID-19 according to the ICD-10, and 26.3% (n = 733) of them submitted clinical specimen for culture. The prevalence of bacterial infection among COVID-19 patients was 16.4%, predominating Gram-negative bacteria (GNB). The respiratory specimen dominated the positive growth culture. The GNB were predominantly discovered among the respiratory and non-respiratory specimens. High range resistance to ampicillin-sulbactam (24-100%), ceftriaxone (22-81%), cefotaxime (22-73%) and ciprofloxacin (20-86%) are observed among the GNB. Conclusion: There is high resistance to fluoroquinolone and cephalosporins in identified isolate, commonly used as the first-line empirical treatment for respiratory and non-respiratory infection in Indonesia. The continuous antibiotic surveillance is mandatory and crucial to prevent the long-term effects of the COVID-19 pandemic, particularly bacterial infection.

Impact of social activity restriction and routine patient screening as a preventive measurement for tertiary referral hospital staff in a country with high COVID-19 incidence.

Background: Measuring COVID-19 incidence among hospital staff and the influencing factors and preventative measures affecting outcomes is important given their high risk of exposure and potential impacts on health service provision. Method: Study participants included all hospital staff with COVID-19 confirmed by real-time reverse transcription-polymerase chain reaction (RT-PCR) from March 2020 to July 2021. Data were collected on age, gender, occupation, working area, symptoms and vaccination status. We also collected data on pediatric oncology patients and their caregivers to review the hospital screening policy. Results: Approximately 59% of positive cases among hospital staff occurred in the green zone; 75% were fully vaccinated. Whole-genome sequencing indicated that staff infections in June 2021 were Delta variant. A decrease in cases coincided with government implementation of social activity restriction. When RT-PCR was performed in suspected cases, 3 of 36 pediatric oncology patients and 10 staff tested positive. After routine screening, 8 of 121 patients, 3 patient caregivers, and 5 staff tested positive, all were asymptomatic, and all were infected in the community. Conclusions: Routine testing for staff, patients and caregivers, vaccination booster programs, continuing education of health care workers, and government policy, such as social activity restriction, are needed to protect frontline workers.

MDR Pathogens Organisms as Risk Factor of Mortality in Secondary Pulmonary Bacterial Infections Among COVID-19 Patients: Observational Studies in Two Referral Hospitals in West Java, Indonesia.

Purpose: The coronavirus disease (COVID-19) outbreak has created a global health crisis. Secondary pulmonary bacterial infection is a COVID-19 complication, increasing morbidity and mortality. This study aimed to determine the pathogens, antibiotic susceptibility patterns, and risk factors for mortality in hospitalized COVID-19 patients. Patients and Methods: This retrospective study used secondary data from patients' electronic medical records at Hasan Sadikin General Hospital and Santo Borromeus Hospital between March 2020 and March 2021. Overall, 2230 hospitalized COVID-19 patients were screened, and 182 of them who were hospitalized ≥48 hours with a procalcitonin level of ≥0.25 ng/mL were enrolled. Culture examination was performed on sputum samples to determine pathogen and antibiotic susceptibilities. Univariate and multivariate analyses were used to determine mortality-related risk factors in hospitalized COVID-19 patients. Results: The prevalence of secondary pulmonary bacterial infections in COVID-19 patients was 8.2%, with 161/182 pathogen growth from sputum samples. Mainly gram-negative bacteria (64.8%) were present, including Acinetobacter baumannii (31.9%), Klebsiella pneumoniae (19.8%), and Pseudomonas aeruginosa (8.8%). High rate of multidrug-resistant (MDR) pathogens was found among isolate (45.9%), ie carbapenem-resistance A. baumannii (CR-Ab) was 84.2%, extended-spectrum ß-lactamase (ESBL) among K. pneumoniae was 61.1%. Secondary infection of MDR pathogens was associated with a higher risk of mortality (AOR 5.63, p = 0.001). Other associated factors were age ≥60 years, ventilator use, and female gender. Conclusion: Gram-negative bacteria are the predominant pathogens causing secondary pulmonary bacterial infection in COVID-19 patients, implying nosocomial infection. High resistance to first-line antimicrobial drugs was observed in Gram-negative bacteria and Gram-positive bacteria. High rate of MDR pathogens was found among isolate and was associated with a significant risk of mortality.

A case of endocarditis and spondylodiscitis associated with Mycobacterium tuberculosis.

Tuberculosis (TB) is a global health problem, in which the majority of cases occur in population-dense developing countries. Despite advances in various diagnostic TB modalities, extrapulmonary TB remains a challenge due to complexities related to its diagnostic approach. Hereby, we present a rare case of endocarditis and spondylodiscitis associated with Mycobacterium tuberculosis (MTB). This case report highlighted the challenges faced in diagnosing blood culture-negative infective endocarditis (BCNIE). We also emphasized the importance of considering MTB as etiology of BCNIE, particularly in endemic TB areas.

A fatal case of early prosthetic valve endocarditis caused by multidrug-resistant (MDR) - Sphingomonas paucimobilis.

Sphyngomonas paucimobilis (S. paucimobilis) is a low-pathogenicity, gram-negative bacilli (GNB) that are previously known as an opportunist microorganism. Recent studies have shown that S. paucimobilis is an emerging pathogen causing various infections. Multidrug-resistant GNB has emerged as a major clinical and therapeutic dilemma in various hospital-associated infections. Although rare, S. paucimobilis could be associated with infective endocarditis (IE). Prosthetic valve endocarditis (PVE) is the most severe type of IE, which has high mortality rates despite diagnostic and treatment advances. We report a fatal case of early PVE associated with multidrug-resistant (MDR) - S. paucimobilis complicated with perivalvular abscess, complete heart block, valve detachment, and septic arthritis.

Delayed definitive treatment of life-threatening neurosurgery patient with suspected coronavirus disease 2019 infection in the midst of pandemic: Report of two cases.

BACKGROUND: Coronavirus disease 2019 (COVID-19) pandemic has affected global health system; in the context of the COVID-19 pandemic, both surgeon and anesthesiologist often dealt with emergency situation, optimal timing of surgery and safety protocol in hospital setting must be implemented with many facets for both patients and health-care providers. CASE DESCRIPTION: We reported two cases. Case#1 - A 16-year-old male was referred to our hospital, due to a decreased of consciousness following a motor vehicle accident. Head CT scan revealed an epidural hemorrhage on the left temporoparietal. The patient was suspected for having COVID-19 from the reactivity of his serum against SARS-CoV-2 antigen. Procedures for the confirmation of COVID-19 and surgical preparation caused 12 h delayed from the admission. Nevertheless, the patient was deteriorated clinically before he was transported to the operating room and died after 6 cycles of cardiopulmonary resuscitation. Case#2 - A 25-year-old male was referred to RSHS, due to a decreased of consciousness, diagnosed as bilateral proximal shunt exposed with suspected COVID-19; delay occurred due to unavailability of negative pressure intensive unit for postoperative care. This caused 5760 h (4 days) delayed for bilateral shunt removal and temporary extraventricular drainage. CONCLUSION: Optimal timing of surgery, a good safety, and health protocol during pandemic in emergency setting are an obligation to protect health providers and patients. A decision-making plan must be organized precisely to maintain alertness, achieve the highest possible standard of care, and outcome in emergency surgical cases. Lack of monitoring must be abated to avoid fatality for patient, especially in emergency surgery setting.

Challenge in diagnosis of COVID-19 in hemodialysis patient: a case report and brief review of the literature.

Diagnosis of COVID-19 in end-stage kidney disease (ESKD) patients on hemodialysis is challenging,  as the symptoms are often atypical. Herein, we reported a confimed case of COVID-19 in a patient on maintenance hemodialysis. A 38-year-old man with ESKD on regular hemodialysis initially presented with progressive shortness of breath and dry cough, without fever. He had lymphopenia, and chest X-ray suggested pulmonary edema with cardiomegaly and suspected bilateral bronchopneumonia. The patient clinically improved after 7 days of hospitalization, and was subsequently discharged from hospital. Ten days after being discharged, the patient was re-admitted with progressive shortness of breath and dry cough, without fever. SARS-CoV-2 infection was later confirmed by a qualitative RT-PCR test and the diagnosis COVID-19 pneumonia was established. We presented a case of atypical presentation of COVID-19 in an ESKD patient on maintenance hemodialysis with a brief review of the current literature.

Report of Two COVID-19 ARDS (CARDS) Cases Who Survived without Intubation and Mechanical Ventilation.

The most severe clinical feature of COVID-19 is Acute Respiratory Distress Syndrome (ARDS) which requires intubation and mechanical ventilation and it occurs in approximately 2.3% of cases. About 94% of of these cases end in death. This case series report two confirmed COVID-19 patients who had met criteria of intubation and mechanical ventilation, but not performed to them. Both patients experienced clinical improvement and recovery. Probably this is due to differences of COVID-19 ARDS (CARDS) with typical or classic ARDS.  CARDS is divided into two phenotypes of type L (Low Elastance) and type H (High Elastance). These different phenotypic also distinguish subsequent pathophysiology and clinical management. These phenotype can be differentiate by chest CT scan. This case series emphasizes the importance of understanding this phenotype so that clinicians can provide more appropriate treatment management and also availability of CT scans in health facilities that manage COVID -19.

Lethal Arrhythmia (Torsade de Pointes) in COVID-19: An Event Synergistically Induced by Viral Associated Cardiac Injury, Hyperinflammatory Response, and Treatment Drug?

Arrhythmias in patients with coronavirus disease 2019 (COVID-19) are prevalent and deserve special attention because they are associated with an increased risk of fatal outcome. The mechanism of arrhythmia in COVID-19 remains unclear. Here, we report our first case of confirmed COVID-19 with documented Torsade de Pointes (TdP). A 64-year-old woman, previously healthy, presented to our emergency department with progressive shortness of breath, dry cough, and 1 week of fever. She was treated with chloroquine phosphate, meropenem, and ciprofloxacin. After 5 days of admission, her condition deteriorated and she was admitted to the intensive care unit. The patient had two episodes of malignant arrhythmias within 24 hours. The former was TdP, and the latter was a fatal pulseless ventricular tachycardia that occured even after chloroquine was discontinued. There was evidence of cardiac injury shown by increased serum level of troponin I. We propose a synergistic concept of lethal arrhythmia due to direct severe acute respiratory syndrome coronavirus (SARS-CoV)-2-associated cardiac injury, hyperinflammatory response, and drug-induced arrhythmia.

Low Body Mass Index as a Risk Factor for Antiretroviral Drug-Related Liver Injury Among HIV Patients.

BACKGROUND: antiretroviral drug-related liver injury (ARLI) is a drug-induced hepatotoxicity due to antiretroviral medication (ARV). It commonly disrupts compliance to treatment and causes treatment discontinuation in HIV-infected patients. Several studies have been conducted on predisposing factors for ARLI including studies on body mass index (BMI) and cluster of differentiation 4 (CD4). The association of BMI and CD4 with ARLI remains controversial as previous studies have demonstrated different outcomes. Our study was conducted to identify the association of low baseline BMI and CD4 cell count as risk factors for ARLI in HIV-infected patients. METHODS: this is a cross-sectional study. Subjects were 75 patients with HIV-AIDS who received ARV therapy using fixed-dose combination  (tenofovir, lamivudine, efavirenz) at the Teratai HIV outpatient clinic of Hasan Sadikin Hospital in Bandung city. Alanine aminotransferase (ALT) test was performed prior to starting ARV treatment and the test was repeated on the sixth month of therapy. RESULTS: there was no significant difference on the proportion of low baseline CD4 count between ARLI and non-ARLI group (p=0.155). Bivariate analysis demonstrated that regarding the proportion of low baseline BMI, there was a significant difference between ARLI and non-ARLI group (p= 0.001). Multivariate analysis using logistic regression showed that BMI of < 18.5 kg/m2 increased the risk for developing ARLI by 5.53 fold; while CD4 cell count of < 200 cells/µL did not the risk. CONCLUSION: our study indicates that low baseline BMI may increase the risk for developing ARLI; while low baseline CD4 cell count does not; therefore, we suggest that ALT test should be performed on a routine basis among HIV-AIDS patients for early detection of ARLI, particularly in patients with low BMI.

Are there differences in HIV retention in care between female and male patients in Indonesia? A multi-state analysis of a retrospective cohort study.

BACKGROUND: Little is known about HIV treatment outcomes in Indonesia, which has one of the most rapidly growing HIV epidemics worldwide. METHODS: We examined possible differences in loss to follow-up (LTFU) and survival between HIV-infected females and males over a 7-year period in an HIV clinic in Bandung, West Java. Data imputation was performed on missing covariates and a multi-state Cox regression was used to investigate the effects of sex and other covariates on patient transitions among four states: (1) clinic enrollment with HIV, (2) initiation/continuation/re-initiation of antiretroviral therapy (ART), (3) LTFU, and (4) death. RESULTS: We followed 3215 patients (33% females), for a total of 8430 person-years. ART was used by 59% of patients at some point. One-year retention was 73% for females and 77% for males (p = 0.06). One-year survival was 98% for both females and males (p = 0.15). Females experienced a higher relative hazard to transition from HIV to LTFU (adjusted hazard ratio 1.21; 95% confidence interval 1.00-1.45), but this decreased after adjustments for clinical variables (aHR 0.94; 95% CI 0.79-1.11). Similarly, a lower relative hazard in females to transition from ART to death (aHR 0.59; 95% CI 0.35-0.99) decreased after adjustments for demographic variables. CONCLUSION: This Indonesian cohort has low ART uptake and poor overall pre- and post-ART retention. Female-male differences in survival and retention were gone after adjusting for clinical and sociodemographic factors such as CD4 count and education level. Efforts should be made to improve retention among patients with lower education.

Improving Diagnostic of Pulmonary Tuberculosis in HIV Patients by Bronchoscopy: A Cross Sectional Study.

BACKGROUND: diagnostic of pulmonary TB in HIV patients is a problem due to non specific clinical features, or radiological appearance. HIV patients with CD4≤200 cells/mL infected with M. tuberculosis have less capacity in containing M. tuberculosis, developing granulomas, casseous necrosis, or cavities. This condition is caused by weakend inflammatory which later reduced sputum production and may cause false negative result. This study aimed to assess differences in the positivity level of acid fast bacilli (AFB) and cultures of M. tuberculosis from non-bronchoscopic sputum (spontaneous and induced sputum) compared to bronchoscopic sputum (bronchoalveolar lavage) in HIV positive patients suspected pulmonary tuberculosis with CD4<200 cells/µL. METHODS: this cross sectional study was conducted in adult HIV patients treated in Hasan Sadikin Hospital with CD4≤200 cells/µL suspected with pulmonary tuberculosis by using paired comparative analytic test. All patients expelled sputum spontaneously or with sputum induction on the first day. On the next day, bronchoalveolar lavage (BAL) was performed. The two samples obtained from two methods were examined by AFB examination with staining Ziehl Neelsen (ZN) and cultured of M. tuberculosis on solid media Ogawa on all patients. Positivity, sensitivity and increased sensitivity of AFB and culture of M. tuberculosis in the non bronchoscopic and bronchoscopic groups were compared. RESULTS: there were differences in the positivity level of AFB with ZN staining between non-bronchoscopic and bronchoscopic groups which were 7/40 (17.5%) vs 20/40 (50.0%) (p<0.001). The differences between the cultures of non-bronchoscopic and bronchoscopic groups were 16/40 (40.0%) vs 23/40 (57.5%) (p=0.039). Bronchoscopic sputum increased the positivity level of the ZN AFB examination by 32.5% (from 17.5% to 50.0%) as well as on culture examination by 17.5% (from 40.0% to 57.5%). CONCLUSION: Bronchoalveolar lavage can improve the positivity level of smears and cultures in patients suspected of pulmonary TB in HIV patients with CD4<200 cells/µL.

Virological failure and drug resistance during first line anti-retroviral treatment in Indonesia.

The virological response and development of drug resistance during first-line anti-retroviral treatment (ART) were studied in Indonesia where the majority of patients infected with HIV have a history of injecting drug use, which is often linked with lower treatment adherence and development of drug-resistance. As many as 575 patients starting ART between September 2007 and March 2010 in Hasan Sadikin Hospital Bandung were followed prospectively. Clinical and laboratory monitoring was performed every 6 months. Plasma samples with HIV-RNA ≥ 400 copies/ml were examined for drug resistance mutations. Most patients were male (72.3%), 59.7% had a history of injecting drug use, and the median CD4+ cells count before start of ART was 35 cells/mm(3) (IQR 10-104). From 438 HIV patients with HIV-RNA measurements, 40 (9.1%) subjects had HIV-RNA ≥ 400 copies/ml after 24 weeks (median follow-up 16 (IQR 8-25) months). Of these failing patients 16 (47%) subjects had drug resistance mutations, predominantly M184V (35.3%), Y181C (23.5%), K103N (11.7%), and TAMs (11.7%). A history of treatment discontinuation ≥ 1 month, reported by 5.3% (23) of patients, was strongly associated with virological failure (adjusted OR 12.64, 95% CI 4.51-35.41); and a history of injecting drug use was not (OR 0.75, 95% CI 0.38-1.46). This is the largest and most systematic evaluation of virological response to first line ART in Indonesia. Patients in this cohort responded well to first line ART, with low rates of virological failure and drug resistance. A history of injecting drug use should not be a reason to withhold ART in this setting.