Tuberculosis-associated immune reconstitution disease: incidence, risk factors and impact in an antiretroviral treatment service in South Africa.
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.
Lawn
Stephen D
SD
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
Myer
Landon
L
Bekker
Linda-Gail
LG
Wood
Robin
R
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
D019380:Anti-HIV Agents; D000995:Antitubercular Agents