Журнал «Актуальная инфектология» Том 7, №2, 2019

Background. Problem of a clinical course of tuberculosis in HIV-infected patients is extremely important nowadays. In recent years, there has been a steady increase in the number of co-infections, which has become a significant problem due to the difficulty of their antimycobacterial therapy (AMBT). One of the reasons for ineffective treatment is the poor tolerability of antimycobacterial drugs (AMBD). The severity of AMBD adverse reactions may vary from mild which is in no need for intervention, but require more close monitoring, to a more severe or life-threatening, where AMBD should be discontinued and prescribe appropriate symptomatic and pathogenetic treatment. Especially severe intolerability is observed in patients with combined pathology. Therefore, in addressing questions of tuberculosis control, an important role is given to timely diagnosis of liver diseases. Over the past decades, ultrasound imaging methods have taken a leading place among the instrumental methods of examination of various organs and systems. This is due to their high informativity, lack of contraindications and relatively affordable cost. The purpose of the study was to evaluate the state of the hepatobiliary system in patients with new cases of co-infection tuberculosis/HIV and concomitant viral hepatitis before the start of AMBT.

Material and methods. The study included 56 patients with the FDTB cases of pulmonary tuberculosis with HIV co-infection, which was treated at the Kyiv City AntiTB Dispensary N1. The study included only those patients who determined the CD4+ T-cell count and were examined for markers of viral hepatitis B and C. All patients were given a biochemical blood test with the following parameters: AST/ALT, bilirubin, gamma-glutamyltransferase (GGT), alkaline phosphatase (ALP), albumin. Ultrasonography of the hepatobiliary system was performed with the TOSHIBA XAR-310 ultrasound diagnostic apparatus. Comparisons were held between groups of patients with of co-infection tuberculosis/HIV in combination with viral hepatitis against patients without viral hepatitis.

Results and discussion. Among all examined patients a liver pathologies were found in 12 patients (21.4 %). Ultrasound signs of portal hypertension were observed in 14 (25 %) cases. Parameters of the portal blood flow were evaluated by the congestion index (CI) and the arterial perfusion index (API). Portal blood flow was considered to be changed when the CI was greater than the reference value (0.034 ± 0.002): if the index was 0.043 ± 0.002, this indicated the presence of fibrous changes in the liver; if it increased to 0.087 ± 0.002 — cirrhosis. Also, portal blood flow was considered changed when the API was greater than the reference value (0.32 ± 0.02): among patients with different stages of fibrosis the average was (0.34 ± 0.02). Some patients (21.4 %) with concomitant viral hepatitis, even before the start of AMBT, had demonstrated ultrasound signs of liver damage such as hepatomegaly, decreased or increased echogenicity of parenchyma and portal blood flow parameters in comparison with patients without viral hepatitis, in which similar changes had not been determined more than 8.0 % of patients (p < 0.05). According to the obtained data, among patients with new cases of co-infection tuberculosis/HIV without viral hepatitis, compared with patients with concomitant viral hepatitis B and C prior to the beginning of AMBT, the enhancement of level of some biochemical parameters were significantly less determined: ALT/AST level more than 40 U/L was in 7.9 % against 36.2 %; bilirubin more than 20 mkmol/l — in 5.3 % against 29.3 %; simultaneous increase of ALT/AST and total bilirubin — 5.3 % against 29.3 %; GGT more than 50 U/L — 31.6 % against — 79.3 %; ALP more than 300 U/L — 18.4 % against 43.1 % respectively. In 22 patients with co-infection tuberculosis/HIV without concomitant viral hepatitis B and/or C experienced adverse reactions (31.8 %) occurred due to dyspeptic and hepatotoxic reactions (HTR). HTR requiring treatment discontinuation occurred in 4 (7.1 %) cases. The most severe risk of developing HTR was found in patients with baseline elevations of ALT/AST more than 2 times or in patients with any simultaneous increase in ALT/AST and bilirubin. A strong connection with the occurrence of HTR was established in case of an increase in the level of bilirubin, a decrease in blood albumin levels of more than 3.5 g/l or ultrasound signs of liver damage. There was no connection between the occurrence of HTR and the initial increase in GGT and ALP. GGT was elevated at the beginning of treatment in half of the patients, however, but this had not affected the development of adverse reactions. In patients with infectious hepatitis, GGT activity was determined 2–5 times higher than normal. The increase in GGT in these cases had been observed longer than other liver enzymes. There is no found connection between the occurrence of HTR and the degree of immune deficiency determined with the CD4+ T-cell count.

Conclusions. Additional diagnostic methods, including ultrasonography, are necessary for the timely diagnosis of liver pathology. Ultrasonography providing is especially important in the presence of concomitant diseases in patients with FDTB, which manifests a miserable clinical symptomatology, especially at an early stage.