Small P M, Schecter G F, Goodman P C, Sande M A, Chaisson R E, Hopewell P C
Medical Service, San Francisco General Hospital Medical Center, CA 94110.
N Engl J Med. 1991 Jan 31;324(5):289-94. doi: 10.1056/NEJM199101313240503.
Infection with the human immunodeficiency virus (HIV) increases the risk of tuberculosis and may interfere with the effectiveness of antituberculosis chemotherapy. To examine the outcomes in patients with both diagnoses, we conducted a retrospective study of all 132 patients listed in both the acquired immunodeficiency syndrome (AIDS) and tuberculosis case registries in San Francisco from 1981 through 1988.
At the time of the diagnosis of tuberculosis, 78 patients (59 percent) did not yet have a diagnosis of AIDS, 18 patients (14 percent) were given a concomitant diagnosis of AIDS (as determined by the presence of an AIDS-defining disease other than tuberculosis), and the remaining 36 patients (27 percent) already had AIDS. The manifestations of tuberculosis were entirely pulmonary in 50 patients (38 percent), entirely extrapulmonary in 40 patients (30 percent), and both pulmonary and extrapulmonary in 42 patients (32 percent). The treatment regimens were as follows: isoniazid and rifampin supplemented by ethambutol for the first two months, 52 patients; isoniazid and rifampin supplemented by pyrazinamide and ethambutol for the first two months, 39 patients; isoniazid and rifampin, 13 patients; isoniazid and rifampin supplemented by pyrazinamide for the first two months, 4 patients; and other drug regimens, 17 patients. The intended duration of treatment for patients whose regimen included pyrazinamide was six months, and for patients who did not receive pyrazinamide, nine months. Seven patients received no treatment because tuberculosis was first diagnosed after death. Sputum samples became clear of acid-fast organisms after a median of 10 weeks of therapy. Abnormalities on all chest radiographs taken after three months of treatment were stable or improved except for those of patients who had new nontuberculous infections. The only treatment failure occurred in a man infected with multiple drug-resistant organisms who did not comply with therapy. Adverse drug reactions occurred in 23 patients (18 percent). For all 125 treated patients, median survival was 16 months from the diagnosis of tuberculosis. Tuberculosis was a major contributor to death in 5 of the 7 untreated patients and 8 of the 125 treated patients. Three of 58 patients who completed therapy had a relapse (5 percent); compliance was poor in all 3.
Tuberculosis causes substantial mortality in patients with advanced HIV infection. In patients who comply with the regimen, conventional therapy results in rapid sterilization of sputum, radiographic improvement, and low rates of relapse.
感染人类免疫缺陷病毒（HIV）会增加患结核病的风险，并可能影响抗结核化疗的效果。为了研究同时患有这两种疾病的患者的治疗结果，我们对1981年至1988年旧金山获得性免疫缺陷综合征（AIDS）和结核病病例登记册中列出的所有132例患者进行了一项回顾性研究。
在诊断结核病时，78例患者（59%）尚未被诊断为艾滋病，18例患者（14%）同时被诊断为艾滋病（根据除结核病外的艾滋病定义疾病的存在来确定），其余36例患者（27%）已经患有艾滋病。结核病的表现完全为肺部症状的有50例患者（38%），完全为肺外症状的有40例患者（30%），肺部和肺外症状均有的有42例患者（32%）。治疗方案如下：前两个月使用异烟肼和利福平并辅以乙胺丁醇，52例患者；前两个月使用异烟肼和利福平并辅以吡嗪酰胺和乙胺丁醇，39例患者；异烟肼和利福平，13例患者；前两个月使用异烟肼和利福平并辅以吡嗪酰胺，4例患者；以及其他药物方案，17例患者。方案中包含吡嗪酰胺的患者预期治疗时长为6个月，未接受吡嗪酰胺的患者为9个月。7例患者未接受治疗，因为结核病是在患者死亡后首次诊断出来的。治疗中位数为10周后，痰标本中的抗酸菌转阴。治疗3个月后拍摄的所有胸部X光片上的异常情况，除了有新的非结核感染的患者外，均保持稳定或有所改善。唯一的治疗失败发生在一名感染了多重耐药菌且未遵守治疗方案的男性患者身上。23例患者（18%）出现了药物不良反应。对于所有125例接受治疗的患者，从诊断结核病起的中位生存期为16个月。在7例未接受治疗的患者中，有5例以及在125例接受治疗的患者中，有8例患者的死亡主要归因于结核病。58例完成治疗的患者中有3例复发（5%）；这3例患者的依从性均较差。
结核病在晚期HIV感染患者中导致了相当高的死亡率。在遵守治疗方案的患者中，常规治疗可使痰快速除菌、X光片情况改善且复发率较低。
