title: Tuberculosis-associated immune reconstitution disease: incidence, risk factors and impact in an antiretroviral treatment service in South Africa.
abstract: OBJECTIVE
  To determine the burden and impact of immune reconstitution disease (IRD) associated with tuberculosis (TB) among patients initiating antiretroviral treatment (ART) in sub-Saharan Africa.
  
  
  METHODS
  Retrospective analysis of a study cohort enrolled over 3 years within a community-based ART service in South Africa.
  
  
  METHODS
  Patients receiving treatment for TB at the time ART was initiated (n = 160) were studied. Cases of TB-associated IRD during the first 4 months of ART were ascertained.
  
  
  RESULTS
  The median baseline CD4 cell count was 68 cells/microl [interquartile range (IQR), 29-133 cells/microl) and ART was initiated after a median of 105 days (IQR, 61-164 days) from TB diagnosis. Although IRD was diagnosed in just 12% (n = 19) of patients overall, IRD developed in 32% (n = 12) of those who started ART within 2 months of TB diagnosis. Pulmonary involvement was observed in 84% (n = 16) and intra-abdominal manifestations were also common (37%). Overall, 4% (n = 7) of the cohort required secondary level health-care for IRD and two (1%) patients died. In multivariate analysis, risk of IRD was strongly associated with early ART initiation and low baseline CD4 cell count. Of patients with CD4 counts < 50 cells/microl, the proportions who developed IRD following initiation of ART within 0-30, 31-60, 61-90, 91-120 and > 120 days of TB diagnosis were 100%, 33%, 14%, 7% and 0%, respectively.
  
  
  CONCLUSIONS
  The risk of TB-associated IRD in this setting is very high for those with low baseline CD4 cell counts initiating ART early in the course of antituberculosis treatment. However, most cases were self-limiting; overall secondary health-care utilization and mortality risk from IRD were low.
authors.affiliation: Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa. stevelawn@yahoo.co.uk
authors.forename: Stephen D
authors.initials: SD
authors.lastname: Lawn
authors.forename: Landon
authors.initials: L
authors.lastname: Myer
authors.forename: Linda-Gail
authors.initials: LG
authors.lastname: Bekker
authors.forename: Robin
authors.initials: R
authors.lastname: Wood
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000150:complications* / Q000188:drug therapy / Q000276:immunology; D000328:Adult; D019380:Anti-HIV Agents / Q000009:adverse effects*; D023241:Antiretroviral Therapy, Highly Active / Q000009:adverse effects; D000995:Antitubercular Agents / Q000009:adverse effects*; D018791:CD4 Lymphocyte Count; D003906:Developing Countries; D004812:Epidemiologic Methods; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000276:immunology; D006801:Humans; D007154:Immune System Diseases / Q000139:chemically induced* / Q000276:immunology; D007249:Inflammation / Q000139:chemically induced / Q000276:immunology; D008297:Male; D013019:South Africa; D014376:Tuberculosis / Q000150:complications* / Q000188:drug therapy
chemical_list: D019380:Anti-HIV Agents; D000995:Antitubercular Agents