A Randomized, Double‐Blind, Placebo‐Controlled Trial of the Use of Prednisolone as an Adjunct to Treatment in HIV‐1–Associated Pleural Tuberculosis

Elliott, Alison M.; Luzze, Henry; Quigley, Maria A.; Nakiyingi, Jessica; Kyaligonza, Steven; Namujju, Proscovia B.; Ducar, Constance; Ellner, Jerrold J.; Whitworth, James; Mugerwa, Roy D.; Johnson, John L.; Okwera, Alphonse

doi:10.1086/422257

Cited by 99 publications

(96 citation statements)

References 27 publications

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“…The degree of residual pleural thickening is not reduced with the administration of corticosteroids. The administration of prednisolone was associated with an increased risk of Kaposi sarcoma in a study of HIV patients with associated pleural TB [83]. At this time, there are insufficient data to support evidence-based recommendations, as outlined in a recent Cochrane review regarding the use of adjunctive corticosteroids in patients with TB pleurisy [84].…”

Section: Corticosteroidsmentioning

confidence: 99%

Tuberculous Pleural Effusion

Cohen

Light

2015

Tur Toraks Der

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When a patient presents with new pleural effusion, the diagnosis of tuberculous (TB) pleuritis should be considered. The patient is at risk for developing pulmonary or extrapulmonary TB if the diagnosis is not made. Between 3% and 25% of patients with TB will have TB pleuritis. The incidence of TB pleuritis is higher in patients who are human immunodeficiency virus (HIV)-positive. Pleural fluid is an exudate that usually has a predominance of lymphocytes. The easiest way to diagnose TB pleuritis in a patient with lymphocytic pleural effusion is to demonstrate a pleural fluid adenosine deaminase level above 40 IU/L. The treatment for TB pleuritis is the same as that for pulmonary TB. Tuberculous empyema is a rare occurrence, and the treatment is difficult. KEY WORDS:Tuberculosis, pleural effusions, adenosine deaminase, gamma interferon, pleural biopsy, empyema INTRODUCTION Tuberculosis (TB) remains a major public health problem in developing countries. Most patients with TB have pulmonary TB; however, 25% of adults can present with extrapulmonary TB, which mainly involves the lymph nodes and pleura but can affect any organ system, including the central nervous system (CNS), cardiovascular system, and gastrointestinal (GI) tract [1]. The most common form of extrapulmonary TB is infection of the pleura. In a patient who presents with undiagnosed pleural effusion, the diagnosis of TB pleuritis should be considered. Pleural effusion, as an isolated manifestation of TB, may be selflimited and of little immediate concern, but untreated, it can lead to serious disease many years later. Pathogenesis and Pathologic FeaturesTuberculous pleural effusion may occur in the absence of radiologically apparent TB [2]. The effusion may result as a sequela to a primary infection from 6-12 weeks earlier, or it may represent the reactivation of TB [2]. In developed countries, TB pleural effusions present more often in older patients. The median age in one North American study was 56, suggesting reactivation of the disease [3]. However, a study from 2004 in San Francisco showed that pleural TB cases were 2 times more likely to be clustered (when assessed by genotyping of the mycobacterial organisms) than pulmonary TB and 3 times more likely to be clustered than nonrespiratory TB cases [4]. The observations made in the San Francisco study suggest that the majority of patients has a postprimary infection [4]. This was not confirmed in studies performed in both Houston [5] and Baltimore [6] or in a study in sub-Saharan Africa, in which the prevalence of pleural TB was 63.2% in patients with a primary TB infection [7].The pathogenesis of TB pleural effusion is thought to be related to the rupture of a subpleural caseous focus in the lung into the pleural space [8]. The basis for this was the observation that a caseous TB focus could be demonstrated in the lung, contiguous with the diseased pleural, in 12 to 15 patients with TB pleuritis [9]. The 3 other patients in this study had parenchymal disease but did not have caseous foci adjacent...

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Section: Corticosteroidsmentioning

confidence: 99%

Tuberculous Pleural Effusion

Cohen

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2015

Tur Toraks Der

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“…In HIV-infected patients, steroids have been shown to be beneficial in tuberculous meningitis, although the overall prognosis is still poor [242]. Steroid use in tuberculous pleural effusion in HIV-infected patients was associated with a higher incidence of Kaposi's sarcoma [243]. An additional concern is that adjuvant steroid therapy of HIV-related tuberculosis has been associated with a transient increase in viral load [244].…”

Section: Adjunctive Immunotherapy In Tuberculosismentioning

confidence: 99%

Treatment of tuberculosis: update 2010

Yew¹,

Lange²,

Leung³

2010

European Respiratory Journal

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Currently, the standard short-course chemotherapy for tuberculosis comprises a 6-month regimen, with a four-drug intensive phase and a two-drug continuation phase. Alternative chemotherapy using more costly and toxic drugs, often for prolonged durations generally .18 months, is required for multidrug-resistant and extensively drug-resistant tuberculosis. Directly observed treatment, as part of a holistic care programme, is a cost-effective strategy to ensure high treatment success and curtail development of drug resistance in tuberculosis. New antituberculosis drugs are urgently needed to improve the present standard short-course and alternative chemotherapies, by shortening administration durations and increasing cure rates, through the greater potency of these agents. At the same time, the role of adjunctive surgery for drug-resistant tuberculosis has to be better defined. Immunotherapy might improve treatment outcomes of both drug-susceptible and -resistant tuberculosis, and warrants further exploration.

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“…In HIV-1-infected adults with pulmonary or pleural TB, corticosteroids do not improve survival or reduce TB recurrence [151][152][153]. A sub study of HIV-1 infected persons within a randomised controlled trial of dexamethasone for TBM in Vietnam showed a trend towards increased survival in the dexamethasone arm [154].…”

Section: Role Of Corticosteroidsmentioning

confidence: 99%

“…There was also more rapid symptom improvement in the prednisone arm [243]. Corticosteroids in HIV-1-infected persons are associated with the risk of Kaposi's sarcoma, herpes virus reactivations, other infections and metabolic side-effects [152,244,245] and should only be used when the diagnosis of paradoxical TB-IRIS is certain and alternative diagnoses have been excluded.…”

Section: Tb-associated Immune Reconstitution Inflammatory Syndromementioning

confidence: 99%