Contribution of tuberculosis to slim disease in Africa

Abstract

Objectives: To assess the contribution of tuberculosis to the aetiology of the HIV wasting syndrome (slim) in Africa, a condition usually considered an enteropathy.

Methods: Clinical examination and representative necropsy study of adult patients positive for HIV.

Setting: Hospital medical wards in Abidjan, Ivory Coast.

Subjects: Adults positive for HIV.

Main outcome measures: CD4 T lymphocyte counts before death, clinical and anthropometric data, and gross and microscopic pathology.

Results: Necropsy was done on 212 HIV positive adults. Tuberculosis was found in 41 of 93 with the clinical HIV wasting syndrome and in 32 of 119 without (odds ratio 2.1, 95% confidence interval 1.2 to 4.0). A significant association existed between the prevalence of tuberculosis at necropsy and the degree of cadaveric wasting (no wasting 25% (15/59); moderate wasting 40% (23/58); skeletal wasting 44% (42/95); P = 0.02). Wasting was also associated with a history of chronic diarrhoea, but no association existed between diarrhoea and tuberculosis. Median CD4 T lymphocyte counts were lowest in wasted patients irrespective of findings at necropsy and in those with chronic diarrhoea (< 60 x 10(6)/l).

Conclusion: Wasting and chronic diarrhoea are late stage manifestations of HIV disease in Africa. The importance of tuberculosis as a contributing factor in the pathogenesis of the slim syndrome has been underestimated. In nearly half of patients dying with severe wasting, tuberculosis was the dominant pathological finding.

PIP: The authors explore the contribution of tuberculosis (TB) to the etiology of HIV wasting syndrome in Africa, usually considered to be an enteropathy. Clinical examinations and necropsy were performed upon 212 HIV positive adults in the medical wards of the largest hospital in Abidjan, Cote d'Ivoire. TB was found in 41 of 93 patients with the clinical wasting syndrome and in 32 of 119 without. Significant associations were found between the prevalence of TB at necropsy and the degree of cadaveric wasting, moderate wasting, and skeletal wasting. Wasting was also associated with a history of chronic diarrhea, but no association existed between diarrhea and TB. Median CD4 counts were lowest in wasted patients irrespective of findings at necropsy and in those with chronic diarrhea. The authors note that wasting and chronic diarrhea are late stage manifestations of HIV disease in Africa and argue that researchers and practitioners have underestimated the importance of TB as a contributing factor in the pathogenesis of slim disease.