Paradoxical Worsening of Tuberculosis Following Antiretroviral Therapy in Patients with AIDS

Abstract

Transient worsening of tuberculous symptomatology and lesions following antituberculous therapy (paradoxical response) has previously been described as a rare occurrence. To determine the incidence of paradoxical responses in patients with AIDS and TB who are treated with antituberculous therapy and subsequently with combination antiretroviral therapy (ARV), we conducted a prospective study of 33 HIV-seropositive TB patients treated with anti-TB therapy and antiretroviral therapy (Group 1) compared with 55 HIV-seronegative TB patients treated with anti-TB therapy (Group 2) and 28 HIV-seropositive TB patients treated with anti-TB therapy but not on antiretrovirals (historical control; Group 3). In Group 1 patients, paradoxical responses were temporally more related to the initiation of ARV than to the initiation of anti-TB therapy (mean +/- SD: 15 +/- 11 d versus 109 +/- 72 d [p < 0.001]) and occurred much more frequently (12 of 33; 36%) compared with Group 2 (1 of 55; 2%) (p < 0.001) or with Group 3 (2 of 28; 7%) (p = 0.013). The majority of patients who experienced paradoxical responses and received tuberculin purified protein derivative (PPD) in Group 1 had their tuberculin skin tests convert from negative to strongly positive after ARV. These observations suggest that a paradoxical response associated with enhanced tuberculin skin reactivity may occur after the initiation of ARV in HIV-infected TB patients. Furthermore, the skin test conversion after the initiation of ARV may have important public health implications.

Remission from Kaposi's sarcoma on HAART is associated with suppression of HIV replication and is independent of protease inhibitor therapy

“…This might be due to partial recovery of anti-HHV-8 immune function, probable infection by wild-type HIV strains and a presumed better adherence compared to previously HAART-treated patients. Nevertheless, paradoxical transient deterioration have been described in KS patients, as seen in patients with tuberculosis and other opportunistic infections (Narita et al, 1998;Baril et al, 2000;Stone et al, 2002). Shelburne et al (2005) showed that patients who have been antiretroviral naive at time of diagnosis of their opportunistic infection have an increased risk of immune inflammatory syndrome.…”

Soft tissue abscess and lymphadenitis due to Mycobacterium avium Complex as an expression of immune reconstitution inflammatory syndrome after a second scheme of highly active antiretroviral therapy

“…KUMARASAMY et al 9 published an incidence of 15.2 cases/100 patients/year to IRIS related with tuberculosis. NARITA et al 14 published a prevalence of 36% for Mycobacterium tuberculosisassociated IRIS.…”

Aparición paradójica de tuberculomas encefálicos durante el tratamiento de tuberculosis en pacientes inmunocompetentes.

“…Narita et al informaron la reacción paradójica a la iniciación del tratamiento antituberculoso en 12 (36%) de 33 pacientes positivos para VIH que concomitantemente iniciaron HAART, en 2 (7%) de 28 pacientes positivos para VIH tratados para tuberculosis antes del advenimiento de la HAART y en 1 (2%) de 55 pacientes negativos para VIH que comenzaron quimioterapia tuberculostática (28).…”