title: Paradoxical worsening of tuberculosis in HIV-infected persons.
abstract: OBJECTIVE
  To determine the incidence of paradoxical worsening of tuberculosis (TB) in HIV-infected persons.
  
  
  METHODS
  Observational cohort study.
  
  
  METHODS
  Public, urban TB clinic.
  
  
  METHODS
  HIV-infected persons treated for TB between January 1, 1996, and December 31, 1999, and followed through June 30, 2000.
  
  
  METHODS
  Patients received standard anti-TB therapy. Antiretroviral therapy was provided by primary medical providers. Patients receiving antiretroviral therapy were given nucleoside reverse transcriptase inhibitors alone or highly active antiretroviral therapy (HAART; nucleoside reverse transcriptase inhibitors in combination with a protease inhibitor or a nonnucleoside reverse transcriptase inhibitor).
  
  
  METHODS
  Paradoxical worsening of TB.
  
  
  RESULTS
  There were 82 TB cases in 76 patients. Paradoxical worsening was identified in 6 of 82 cases (7%; 95% confidence interval, 3 to 15%). Paradoxical worsening occurred in 3 of 28 cases (11%) in patients receiving HAART and in 3 of 44 cases (7%) in patients not receiving antiretroviral therapy (p = 0.67). Cases complicated by paradoxical worsening were more likely to have both pulmonary and extrapulmonary disease at initial diagnosis than cases without paradoxical worsening (83% vs 24%; p = 0.006). TB relapse occurred in 2 of 6 cases (33%) in patients with paradoxical worsening and in 4 of 76 cases (5%) in patients without paradoxical worsening (p = 0.06).
  
  
  CONCLUSIONS
  Paradoxical worsening of TB occurred less frequently than in previous reports and was not associated with HAART. Paradoxical worsening also appeared to be associated with an increased risk of TB relapse. Further studies are warranted to better characterize the risk factors for paradoxical worsening and the appropriate duration of anti-TB therapy in patients in whom it occurs.
authors.affiliation: Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore 21287, USA. kwwendel@mail.jhmi.edu.
authors.forename: K A
authors.initials: KA
authors.lastname: Wendel
authors.forename: K S
authors.initials: KS
authors.lastname: Alwood
authors.forename: R
authors.initials: R
authors.lastname: Gachuhi
authors.forename: R E
authors.initials: RE
authors.lastname: Chaisson
authors.forename: W R
authors.initials: WR
authors.lastname: Bishai
authors.forename: T R
authors.initials: TR
authors.lastname: Sterling
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000188:drug therapy / Q000503:physiopathology*; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use; D023241:Antiretroviral Therapy, Highly Active / Q000009:adverse effects; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D008297:Male; D018894:Reverse Transcriptase Inhibitors / Q000627:therapeutic use; D014376:Tuberculosis / Q000188:drug therapy / Q000503:physiopathology*
chemical_list: D019380:Anti-HIV Agents; D018894:Reverse Transcriptase Inhibitors