title: Clinical presentation and outcome of patients with HIV infection and tuberculosis caused by multiple-drug-resistant bacilli.
abstract: OBJECTIVE
  To determine the clinical manifestations of patients with human immunodeficiency virus (HIV) infection and tuberculosis caused by multiple-drug-resistant bacilli compared with those with single-drug-resistant or susceptible bacilli.
  
  
  METHODS
  Descriptive, case-control, and cohort studies.
  
  
  METHODS
  A large urban teaching hospital.
  
  
  METHODS
  Sixty-two patients with tuberculosis caused by multiple-drug-resistant bacilli (cases) and 55 patients with tuberculosis caused by single-drug-resistant or susceptible bacilli (controls).
  
  
  METHODS
  Characteristics of clinical presentation, radiographs, pathologic abnormalities, antituberculosis treatment, and clinical course.
  
  
  RESULTS
  Twenty cases (32%) had concomitant pulmonary and extrapulmonary disease at presentation compared with 9 controls (16%; odds ratio, 2.4; 95% CI, 1.0 to 5.9). More cases had alveolar infiltrates (76%; odds ratio, 3.6; CI, 1.2 to 11.4), interstitial infiltrates with a reticular pattern (67%; odds ratio, 7.8; CI, 1.0 to 83.5), and cavitations (18%; odds ratio, 6.6; CI, 0.8 to 315.3) on initial chest radiographs compared with controls (49%, 19%, and 3%, respectively). Pathologic specimens from cases showed extensive necrosis, poor granuloma formation, marked inflammatory changes with a predominance of neutrophils, and abundant acid-fast bacilli. Twenty-five cases received two or more effective antituberculosis drugs for more than 2 months. Only 2 cases had three consecutive negative cultures for Mycobacterium tuberculosis; one patient died within 1 day of the last negative culture, and the other had positive cultures 496 days later. The remaining 23 cases had persistently or intermittently positive cultures despite therapy. The clinical course of these cases suggested overwhelming miliary tuberculosis with involvement of the lungs (77%), pleura (15%), stool (34%), meninges (13%), bone marrow (16%), blood (10%), lymph nodes (10%), and skin (8%). The median survival time was 2.1 months for cases compared with 14.6 months for controls (P = 0.001, log-rank test).
  
  
  CONCLUSIONS
  Tuberculosis caused by multiple-drug-resistant bacilli in patients with HIV infection is associated with widely disseminated disease, poor treatment response with an inability to eradicate the organism, and substantial mortality.
authors.affiliation: University of Miami School of Medicine, Department of Medicine, FL 33101.
authors.forename: M A
authors.initials: MA
authors.lastname: Fischl
authors.forename: G L
authors.initials: GL
authors.lastname: Daikos
authors.forename: R B
authors.initials: RB
authors.lastname: Uttamchandani
authors.forename: R B
authors.initials: RB
authors.lastname: Poblete
authors.forename: J N
authors.initials: JN
authors.lastname: Moreno
authors.forename: R R
authors.initials: RR
authors.lastname: Reyes
authors.forename: A M
authors.initials: AM
authors.lastname: Boota
authors.forename: L M
authors.initials: LM
authors.lastname: Thompson
authors.forename: T J
authors.initials: TJ
authors.lastname: Cleary
authors.forename: S A
authors.initials: SA
authors.lastname: Oldham
mesh_terms: D000163:Acquired Immunodeficiency Syndrome / Q000150:complications*; D000328:Adult; D000995:Antitubercular Agents / Q000008:administration & dosage / Q000494:pharmacology*; D016022:Case-Control Studies; D015331:Cohort Studies; D004352:Drug Resistance, Microbial; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D008297:Male; D009169:Mycobacterium tuberculosis / Q000187:drug effects*; D016016:Proportional Hazards Models; D016019:Survival Analysis; D016896:Treatment Outcome; D014397:Tuberculosis, Pulmonary / Q000150:complications / Q000188:drug therapy / Q000382:microbiology* / Q000473:pathology
chemical_list: D000995:Antitubercular Agents