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INFECTION: Karen A. Wendel, Karla S. Alwood, Regina Gachuhi, Richard E. Chaisson, William R. Bishai, and Timothy R. Sterling Paradoxical Worsening of Tuberculosis in HIV-Infected Persons Chest 2001; 120: 193-197 [Abstract] [Full text] [PDF]

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Sequence of HAART/anti-mycobacterial therapy and nadir CD4 count might be important for Tb flare up

Furrer Hansjakob   (28 August 2001)

Sequence of HAART/anti-mycobacterial therapy and nadir CD4 count might be important for Tb flare up 28 August 2001
Furrer Hansjakob, MD Division of Infectious Diseases, University Hospital Berne, CH-3010 Berne, Switzerland Send letter to journal: Re: Sequence of HAART/anti-mycobacterial therapy and nadir CD4 count might be important for Tb flare up hansjakob.furrer{at}insel.ch Furrer Hansjakob	With great interest I read and enjoyed the paper by Wendel et al (Chest 2001; 120: 193-197). They could not find a statistically significant association of HAART and paradoxical worsening of Tb. From our clinical experience we suspect that the sequence of antimycobacterial treatment and HAART as well as the nadir CD4 count might be important. The patients with extrapulmonary Tb we observed and described (Am J Med 1999; 106:371-372) all started antimycobacterial treatment before HAART. They all had CD4 counts below 50 cells/µl at the time of Tb diagnosis. Within a few days after starting HAART we observed the Tb flare-up. Could the authors further characterize their patients who experienced paradoxical worsening of Tb while taking HAART with regard to (i) sequence of antimycobacterials and HAART and (ii) CD4 count at the time of Tb diagnosis. If half of the patients with CD4 count below 50 at the time of Tb- diagnosis who started HAART several weeks after Tb-treatment experienced paradoxical worsening, these factors would characterize a potentially critical situation. This could help physicians to foresee the clinically troublesome worsening of symptoms and e.g. counteract early with corticosteroids. Yours sincerely Hansjakob Furrer, MD