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. 2023 May 8:32:100374.
doi: 10.1016/j.jctube.2023.100374. eCollection 2023 Aug.

Long-term HIV and tuberculosis outcomes in patients hospitalised with severe cutaneous adverse reactions

S Veenstra  1 , M N Porter  2 , B N Thwala  2 , N Pillay  3 , M A Panieri  3 , J van der Westhuizen  4 , E J Phillips  5 , G Meintjes  6 , S Dlamini  7 , R J Lehloenya  8 , J Peter  2   9
Affiliations

Long-term HIV and tuberculosis outcomes in patients hospitalised with severe cutaneous adverse reactions

S Veenstra et al. J Clin Tuberc Other Mycobact Dis. .

Abstract

Background: Treatment-limiting severe cutaneous adverse reactions (SCAR) occur more commonly amongst persons with HIV-associated tuberculosis (TB). The impact of SCAR on long-term HIV/TB outcomes is unknown.

Methods: Patients with TB and/or HIV admitted to Groote Schuur Hospital, Cape Town, South Africa with SCAR between 1/10/2018 and 30/09/2021 were eligible. Follow-up data was collected for 6- and 12-month outcomes: mortality, TB and antiretroviral therapy (ART) regimen changes, TB treatment completion, and CD4 count recovery.

Results: Forty-eight SCAR admissions included: 34, 11, and 3 HIV-associated TB, HIV-only and TB-only patients with 32, 13 and 3 cases of drug reaction with eosinophilia and systemic symptoms, Stevens-Johnson syndrome/toxic epidermal necrolysis and generalised bullous fixed-drug eruption respectively. Nine (19%), all HIV-positive (eight co-infected with TB), were deceased at 12-months, and 12(25%) were lost to follow-up. Amongst TB-SCAR patients, seven (21%) were discharged on all four first-line anti-TB drugs (FLTD), while 12(33%) had regimens with no FLTDs; 24/37(65%) completed TB treatment. Amongst HIV-SCAR patients, 10/31(32%) changed ART regimen. If retained in care (24/36), median (IQR) CD4 counts increased at 12-months post-SCAR (115(62-175) vs. 319(134-439) cells/uL).

Conclusion: SCAR admission amongst patients with HIV-associated TB results in substantial mortality, and considerable treatment complexity. However, if retained in care, TB regimens are successfully completed, and immune recovery is good despite SCAR.

Keywords: CD4 count; DRESS; Drug allergy; Mortality; SJS/TEN; Viral load.

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Conflict of interest statement

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Figures

Fig. 1A
Fig. 1A
Explanations of study period, sampling windows and outcomes. The study included prospective cases with different outcomes as the following example cases show: Case A. Admission for FLTD-SCAR with SDC in hospital, prolonged or modified TB treatment and follow-up clinical information available to collect for 6- and 12-months; Case B. Admission for FLTD-SCAR and then dead either during admission or in the 12-month follow up period, and Case C. Admission for FLTD-SCAR with SDC in hospital, prolonged or modified TB treatment and then loss-to-follow-up during the 12-months post-SCAR. FLTD, first-line anti-tuberculosis drugs; GSH, Groote Schuur Hospital; LTFU, loss to follow up; PHC, primary health care; SCAR, severe cutaneous adverse reaction; SDC, sequential drug challenge; TB, tuberculosis.
Fig. 1B
Fig. 1B
Flow diagram of included patients. Subclassification by SCAR phenotype with numbers of HIV, TB and co-infected in each SCAR phenotype. SCAR not related to HIV or TB treatment was not included. One patient had missing data and was admitted to another tertiary hospital and was therefore not included. DRESS, drug rash with eosinophilia and systemic symptoms; GBFDE, generalized bullous fixed-drug eruption; HIV, human immunodeficiency virus; SCAR, severe cutaneous adverse reaction; SJS/TEN, Stevens-Johnson syndrome/Toxic epidermal necrolysis; TB, tuberculosis.
Fig. 2
Fig. 2
CD4 trends over time in overall, HIV-associated TB, DRESS and SJS/TEN phenotypes. Median CD4 (cells/uL) counts at baseline, 6 months and 12 months for the overall cohort, co-infected subgroup and DRESS and SJS/TEN SCAR phenotypes. GFBDE CD4 trends were not included as there was limited CD4 information available for the three patients with this SCAR phenotype. DRESS, drug rash with eosinophilia and systemic symptoms; GBFDE, generalised bullous fixed-drug eruption; HIV, human immunodeficiency virus; SCAR, severe cutaneous adverse reaction; SJS/TEN, Stevens-Johnson syndrome/toxic epidermal necrolysis; TB, tuberculosis.
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