Impact of human immunodeficiency virus infection on tuberculosis in Kigali, Rwanda: one-year study of 377 consecutive cases

Objectives:
To analyze and compare the clinical, diagnostic, and therapeutic features of tuberculosis (TB) in human immunodeficiency virus (HIV)-seropositive and seronegative patients.
Methods:
A 1-year retrospective review of medical records and charts of TB patients admitted to and followed-up at the Department of Internal Medicine of the Centre Hospitalier de Kigali (CHK), Kigali, Rwanda.
Results:
Tuberculosis was diagnosed in 510 patients. Complete data, including HIV serologic testing, were available for 377 patients (74%) of whom 227 were male and 150 female, aged 17–70 years (mean, 33 y). Human immunodeficiency virus antibodies were detected in 334 (88.6%) of the 377 evaluable patients. A definite diagnosis of TB was established in similar proportions of HIV-seropositive (66%) and HIV-seronegative (63%) patients. The HIV-infected patients differed from the patients without HIV infection in the following features: proportion of patients in the age group 20–39 years (80% vs. 58%; P = 0.001), extrapulmonary manifestations (56% vs. 40%; P = 0.045), lower/middle lobe infiltrates (18% vs. 6%; P = 0.07), presence of cavities (15% vs. 34%; P = 0.002), pleural disease (23 vs. 12%; P = 0.08), tuberculin anergy (67% vs. 26%; P < 0.001). After 6 months of anti-TB therapy, both HIV-infected and HIV-uninfected patients with smear positive pulmonary TB had their sputum samples cleared of acid-fast organisms. Adverse drug reactions occurred in 16% and 7% of HIV-seropositive and seronegative patients, respectively (P = 0.11). The 31% mortality rate (57 of 186) among HIV-infected patients who fulfilled the criteria of the World Health Organization (WHO) clinical case definition for acquired immunodeficiency syndrome (AIDS) was significantly higher than the 7% mortality rate (5 of 76) in HIV-infected patients who did not meet these criteria (P = 0.001) and the 12% mortality rate (5 of 43) in those without HIV infection (P = 0.003).
Conclusions:
Active TB was strongly associated with HIV infection in urban Rwanda. The clinical and radiographic presentation of TB, described in HIV-seropostive patients hospitalized at teh CHK, is most frequently atypical and highly suggestive of advanced HIV disease.