Abstract
BackgroundThe majority of patients with multidrug-resistant tuberculosis (MDR-TB) in South Africa are co-infected with HIV, but the radiographic features of MDR-TB and their relationship with time to sputum culture conversion in the antiretroviral therapy era have not been described.MethodsWe reviewed baseline chest radiographs for 56 patients with MDR-TB from a rural area of South Africa. We analyzed the association of cavities, consolidation, pleural effusion and hilar lymphadenopathy with time to sputum culture conversion, adjusting for HIV status, baseline sputum smear and CD4 count.ResultsOf the 56 subjects, 49 (88%) were HIV-positive, with a median CD4 count of 136 cells/mm3 (IQR 65-249). Thirty-two (57%) patients were sputum smear positive. Twenty-two (39%) patients had a cavity and 37 (66%) patients had consolidations. Cavitary disease and consolidations were each associated with longer time to culture conversion on bivariate analysis but not after adjusting for sputum smear status (aORs 1.79 [0.94-3.42] and 1.09 [0.67-1.78], respectively). Positive baseline sputum smear remained independently associated with longer time to conversion (aOR 3.45 [1.39-8.59]). We found no association between pleural effusion or hilar lymphadenopathy and time to conversion. Seventy-nine percent of patients were cured at the end of treatment.ConclusionsDespite high rates of HIV co-infection and advanced immunodeficiency, the majority of patients had severe pathology on baseline chest radiograph. Nevertheless, culture conversion rates were high and treatment outcomes were favorable. Cavitation and consolidation do not appear to have an independent association with time to culture conversion beyond that of baseline sputum smear status.
Highlights
Multidrug-resistant tuberculosis (MDR-TB), defined as resistance to at least isoniazid and rifampin, remains a growing threat to TB control worldwide and is associated with high mortality—especially in the setting of HIV co-infection [1,2]
Since 2005, routine mycobacterial culture and drug-susceptibility testing (DST) has been available for all TB suspects in Tugela Ferry. This differs from other district hospitals in South Africa, and from that recommended by national policy, which reserves culture and DST for patients who are either being re-treated for TB, or who are failing firstline therapy [15]
Forty-nine (88%) patients were HIV-positive with a median CD4 count of 136 cells/mm3 (IQR 65-249) at the time of multidrug-resistant tuberculosis (MDR-TB) treatment initiation
Summary
Multidrug-resistant tuberculosis (MDR-TB), defined as resistance to at least isoniazid and rifampin, remains a growing threat to TB control worldwide and is associated with high mortality—especially in the setting of HIV co-infection [1,2]. Decreased time to sputum culture conversion has been an useful early predictor of successful final treatment outcome and several studies have found that cavitary disease on chest radiograph is associated with a longer time to culture conversion in drug-susceptible TB [5]. These and other studies have shown that while patients with HIV are less likely to have cavitary disease, they are more likely to have poor outcomes from TB [6,7,8]. The majority of patients with multidrug-resistant tuberculosis (MDR-TB) in South Africa are co-infected with HIV, but the radiographic features of MDR-TB and their relationship with time to sputum culture conversion in the antiretroviral therapy era have not been described
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