Features of the course of tuberculosis in HIV-infected people, depending on the presence of viral hepatitis C

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Introduction. Currently, about 40 million people in the world are living with HIV infection, more than 200 million with HCV virus infection and 10 million with a combination of HIV/HCV, which poses a serious threat to the socio-economic condition of the country due to disability, treatment costs, disability and mortality of the population. Tuberculosis, HIV infection and viral hepatitis account for 90% of deaths from infectious diseases [3]. A distinctive feature of the current course of tuberculosis is an increase in the proportion of combined pathologies such as HIV infection and viral hepatitis. A feature of HCV infection is considered to be a high risk of developing a chronic form, and with mixed HIV/HCV infection, there is a pronounced progression and formation of cirrhosis of the liver compared with HCV monoinfection. This creates additional difficulties in the management of tuberculosis patients with combined pathology, and as a result leads to a decrease in the effectiveness of treatment of patients [1, 2]. The question of the mutual effect of tuberculosis and chronic viral hepatitis C is of great interest due to the leading role of the liver in detoxification, immune response and metabolism of anti-tuberculosis drugs [4].The purpose of the work: To study the features of the course of tuberculosis in HIV-infected people with hepatitis C. Research materials and methods. A retrospective analysis of medical records of inpatient patients with tuberculosis combined with HIV infection who were treated and examined at the Voronezh Regional Clinical Tuberculosis Dispensary named after N.S. Pokhvisneva was carried out. All patients were divided into 2 groups. The main group consisted of tuberculosis patients with HIV infection and hepatitis C (n= 414), the comparison group consisted of tuberculosis patients with HIV infection without hepatitis C (n= 98). The age composition of patients, their social status, ways of detecting the disease, the frequency of bacterial excretion, and the presence of destruction in lung tissue were studied. The prescription and stage of HIV infection, the number of CD4+ cells at the time of tuberculosis detection were also analyzed. The prescription of hepatitis C, liver function parameters, tolerance of anti-tuberculosis drugs.The results of the study. During the period 2020-2023, 512 cases of tuberculosis were detected in patients with HIV infection. The average age of the patients was 40.5 years. All patients were divided into two groups: the main group consisted of tuberculosis patients with HIV infection and hepatitis C – 414 (80.8%) people, the second group consisted of tuberculosis patients with HIV infection without hepatitis C – 98 (19.2%).The average age of patients in the first group was 40.6 years, and in the second group 40.5 years.When studying the social status of patients, it was found that there were 258 (62.3%) unemployed in the main group, 68 (69.4%) in the comparison group, 80 (19.3%) low–income people in the main group, and 23 (23.5%) in the comparison group; in the main group, 58 (14%) patients had a history of imprisonment, in the comparison group 6 (6.12%); in the main group 52 (12.6%) patients lived in unsatisfactory living conditions, in the comparison group 8 (8.16%) people.In the main group, tuberculosis was detected during medical examination in 168 (40.5%) patients, in the comparison group in 57 (58.16%) patients. Tuberculosis was detected in 246 (59.5%) patients of the main group during self-treatment, 41 (41.84%) patients of the comparison group.When studying the clinical forms of pulmonary tuberculosis, it was found that the infiltrative form of tuberculosis was more often detected in the first group – 220 (53.14%) cases, and in the second group this form prevailed in 59 (60.2%) patients. Disseminated tuberculosis in the first group occurred in 151 (36.5%) people, in the second – in 33 (33,7). 20 (4,83%) cases of bilateral caseous pneumonia among patients in the main group and 3 (3.06%) cases from the comparison group. Fibrotic cavernous tuberculosis was also detected in 13 (3.14%) patients in the main group, and 2 (2.04%) in the comparison group. The focal form of pulmonary tuberculosis was detected in 8 (1.93%) patients from the first group, 1 (1.02%) patient from the second group. 1 (0.23%) case of cirrhotic pulmonary tuberculosis in a patient was detected in the main group, and 1 (0.23%) person from the first group was also diagnosed with pulmonary tuberculosis.The features of clinical and radiological manifestations and the course of tuberculosis in patients with HIV infection and hepatitis C include the presence of destructive changes in the lungs. In 208 (50.2%) patients of the main group, the process was in the disintegration phase, in 37 (37.8%) patients of the comparison group. Bacterial excretion was recorded in 253 (61.1%) patients of the main group and in 52 (53.06%) patients of the comparison group.In 276 (66.67%) patients of the main group, tuberculosis was detected against the background of HIV infection, in 57 (58.2%) people of the comparison group. 138 (33.33%) patients in the main group were diagnosed with tuberculosis for the first time, followed by HIV infection in 41 (41.8%) patients in the comparison group.In the main group, the CD4 cell level was more than 500 cells/ml in 112 (27.0%) people, 499-200 cells/ml in 217 (52.5%) people, less than 200 cells/ml in 85 (20.5%) people; in the comparison group, more than 500 cells/ml in 15 (15.3%) patients, 499-200 – 37 (37.8%) patients, less than 200 cells/ml – 46 (46.9%) patients. In the main group, hepatitis C was asymptomatic and chronic in 353 (85.2%) patients.147 (35.5%) patients in the first group had a drug-sensitive chemotherapy regimen, while 56 (57.14%) patients in the second group. Isoniazid-resistant tuberculosis in 27 (6.5%) people in the main group, as well as 9 (9.18%) patients in the comparison group. There were 169 (40.8%) patients with multidrug resistance in the first group, 29 (29.6%) in the second group. There were 33 (8.0%) people with advanced drug resistance in the main group, and 2 (2.04%) people in the comparison group. Broad drug resistance was also found in 38 (9.2%) people in the main group, and in 2 (2.04%) patients in the comparison group.There was an increase in liver enzymes – alanine aminotransferase (ALAT) and aspartate aminotransferase (ASAT). An increase in ALT to the upper 5 limits of normal (ULN) in the main group was observed in 71 (17.2%) patients, in the comparison group in 18 (18.4%); an increase in ALT from 5 to 10 ULN in the first group was noted in 10 (2.4%) people, in the second group in 3 (3.06%) patients; over 10 ULN – 4 (0.97%) patients from the main group, 1 (1.02%) patient from the comparison group. An increase in ASAT to 5 ULN in the first group was observed in 98 (23.7%) patients, in the second group – 18 (18.4%) people; an increase in ASAT from 5 to 10 ULN – 11 (2.66%) cases in the main group, in the comparison group – 1 (1.02%); an increase above 10 ULN It was recorded in 8 (1.93%) patients of the main group, in 1 (1.02%) patient from the comparison group.During therapy, pyrazinamide was discontinued in 25 (6.04%) patients in the main group of patients due to undesirable effects, and in 15 (15.3%) patients in the comparison group. Ethambutol was discontinued in 13 (3.14%) patients from the first group, in the second group in 2 (2.04%) patients. Levofloxacin was also excluded from treatment in 12 (2.9%) people from the main group and in 1 (1.02%) people from the comparison group. Moxifloxacin was discontinued in 1 (1.02%) of the comparison group. Cycloserine withdrawal in the main group in 26 (6.28%) people, in the comparison group in 1 (1.02%). Prothionamide was excluded from treatment in 3 (0.72%) patients from the first group. Aminosalicylic acid (PAS) was eliminated in 4 (0.97%) people in the main group. Withdrawal of bedaquiline in the first group in 6 (1.45%) patients, in the comparison group – 1 (1.02%) case. Delamanide was abolished in 2 (0.48%) people of the first group. Amikacin and capreomycin were discontinued in the main group in 2 (0.48%) patients. In the comparison group, rifampicin was discontinued in 1 (1.02%) patient, and rifabutin was discontinued in 2 (2.04%) patients.Conclusion. The course of tuberculosis in HIV-infected patients differs significantly depending on the presence of hepatitis C, so generalization of the process is most common in patients of the main group – 92 (82.8%) cases. Pulmonary tuberculosis in the decay phase is 5 times more common, and active isolation of Mycobacterium tuberculosis in the first group of patients is 4 times more common. In the main group, patients were 3.5 times more likely to interrupt treatment than in the comparison group. The regimen of multidrug–resistant tuberculosis prevails in the first group – 169 patients (40.8%), in the second group - drug-sensitive tuberculosis - 56 (57.14%) cases. Patients with TB/HIV/HCV have an increased risk of hepatotoxicity on the background of antiretroviral and anti-tuberculosis therapy, as these patients have an increase in liver enzymes 5 times more often, in contrast to the comparison group. A larger number of patients in the main group required the withdrawal of anti–tuberculosis drugs - 93 (22.5%) patients. Thus, the presence of hepatitis C in patients with TB/HIV significantly complicates the clinical picture, therapy and prognosis.

About the authors

Elizaveta Yuryevna Berezina

Voronezh State Medical University named after N.N. Burdenko

Author for correspondence.
Email: els.vs@yandex.ru
ORCID iD: 0009-0009-5272-8179

Student of the Faculty of Medicine, 6th year

Russian Federation, 12 Studencheskaya Street, 394036 Voronezh, Russian Federation

Olga Viktorovna Velikaya

Voronezh State Medical University named after N.N.Burdenko

Email: kftiziatrii@vrngmu.ru
ORCID iD: 0000-0002-0769-8427

Doctor of Medical Sciences, Associate Professor, Head of the Department of Phthisiology

Russian Federation, 12 Studencheskaya Street, 394036 Voronezh, Russian Federation

Olga Sergeevna Martyshova

Voronezh State Medical University named after N.N.Burdenko

Email: kftiziatrii@vrngmu.ru
ORCID iD: 0000-0002-2210-0323

Candidate of Medical Sciences, Associate Professor

Russian Federation, 12 Studencheskaya Street, 394036 Voronezh, Russian Federation

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