Tuberculosis in HIV infection

Symptoms, clinical picture and prognosis of tuberculosis depend on the stage of HIV infection and are caused by the degree of violation of the immune response.

Clinical classification of HIV infection

1. Stage of incubation.
2. The stage of primary manifestations.

Variants of flow

• A. Asymptomatic.
• B. Acute infection without secondary diseases.
• B. Acute infection with secondary diseases.

3. Subclinical stage.
4. Stage of secondary diseases.

4A. Loss of body weight less than 10%. Fungal, viral, bacterial lesions of the skin and mucous membranes, repeated pharyngitis, sinusitis, shingles.

Phases.

• progression in the absence of antiretroviral therapy, against antiretroviral therapy;
• remission (spontaneous, after antiretroviral therapy, against antiretroviral therapy).

4B. Weight loss of more than 10%. Unexplained diarrhea or fever for more than a month, repeated persistent viral, bacterial, fungal, protozoal lesions of internal organs, localized Kaposi's sarcoma, repeated or disseminated herpes zoster. Phases.

• progression in the absence of antiretroviral therapy, against antiretroviral therapy;
• remission (spontaneous, after antiretroviral therapy, against antiretroviral therapy).

4B. Cachexia. Generalized viral, bacterial, mycobacterial. Fungal, protozoal, parasitic diseases, including: Candidiasis of the esophagus, bronchi, trachea, lungs; pneumocystis pneumonia; malignant tumors; lesions of the central nervous system.

Phases.

• progression in the absence of antiretroviral therapy, against antiretroviral therapy;
• remission (spontaneous, after antiretroviral therapy, against antiretroviral therapy).

5. Terminal stage.

In the stage of incubation of HIV infection, before the onset of seroconversion, active reproduction of the virus takes place, which often leads to immunodeficiency. In conditions of a decrease in the body's immune response in infected with mycobacteria, tuberculosis may develop in this period, which is often regarded as a manifestation of late stages of HIV infection (stages 4B, 4B and 5). In connection with which they erroneously determine the prognosis and prescribe non-treatment and dispensary observation that do not correspond to these stages.

The beginning of the stage of primary manifestations taking place in the form of an acute infection is noted more often in the first 3 months after infection. It can outstrip seroconversion (the appearance of antibodies to HIV in the blood), so in patients with tuberculosis, belonging to the high-risk group of HIV infection, it is advisable to re-examine after 2-3 months. The clinical manifestations of tuberculosis in this stage of HIV infection do not differ from those of non-HIV-infected patients.

Long-term follow-up of patients who have transferred tuberculosis at the stage of primary manifestations shows that after a transient decrease in the immune status, its recovery takes place and the usual treatment of tuberculosis produces a good effect. After the completion of the main course of treatment, the general state of patients is often satisfactory for many years: there are no relapses of tuberculosis, the immune status does not undergo significant changes, and there are no other secondary diseases. HIV infection during this period may bring additional clinical manifestations that need to be differentiated from tuberculosis: an increase in lymph nodes, a liver, a spleen; diarrhea, meningeal symptoms.

The main clinical manifestation of HIV infection in the latent stage is persistent generalized lymphadenopathy. It must be differentiated from tuberculosis of peripheral lymph nodes. With persistent generalized lymphadenopathy, the lymph nodes are usually elastic, painless, not soldered to the surrounding tissue, the skin over them is not changed. The duration of the latent stage varies from 2-3 to 20 years or more, but on average it lasts 6-7 years.

In conditions of continuous replication of the virus in the human body infected with HIV, the compensatory possibilities of the immune system at the end of the latent stage decrease and develop a pronounced immunodeficiency. The probability of developing tuberculosis increases again, with the more pronounced immunodeficiency becomes. The more changes in tissue reactions to the causative agent of tuberculosis: productive reactions are lost, alternative reactions with dissemination of the pathogen prevail.

In stage 4A, the first manifestations of secondary diseases characteristic of HIV infection appear. Since the immunodeficiency is not expressed during this period, the clinico-radiologic and morphological picture, as a rule, does not differ from the pattern characteristic for tuberculosis.

In patients in stage 4B, which usually develops 6-10 years after HIV infection, the radiographic pattern increasingly acquires atypical features.

In stage 4B, there are even more pronounced deviations from typical manifestations of tuberculosis, the generalization of the process is typical, often with no changes at all on the chest radiographs. Against the background of significant immunodeficiency, other secondary diseases develop, which makes the diagnosis of tuberculosis even more difficult.

In the late stages of HIV infection (4B, 4B and 5), disseminated processes and tuberculosis of the intrathoracic lymph nodes predominate in the structure of the forms of tuberculosis (more than 60%).

Often, an x-ray triad is determined: bilateral focal or focal dissemination, an increase in three or more groups of intrathoracic lymph nodes, exudative pleurisy, and a rapid change in the changes in the radiographic pattern is possible both in the positive and in the negative direction. Decay cavities in the late stages of HIV infection are detected only in 20-30% of cases, which is associated with a change in tissue reactions against a background of severe immunodeficiency.

A bright clinical picture can outpace the emergence of dissemination for 4-14 weeks. In a number of patients, the X-ray can not detect changes at all. Among the clinical manifestations of the prevalence of severe intoxication: a sharp sweating, temperature rises to 39 ^o C. In a number of cases, patients are troubled by a painful cough with very sparse phlegm; he may be absent. In a third of patients, cachexia is detected.

The percentage of bacterial discharges among patients in the "late" stages of HIV infection is no more than 20-35%, which is associated with a decrease in the number of tuberculosis cases in the phase of decay during this period. Tuberculin tests in the "late" stages of HIV infection are in most cases not informative.

When pathomorphological examination of the removed lymph nodes, massive conglomerates with total caseosis are often determined.

In the morphological study, predominantly alterative reactions (necrosis) are recorded - 76%. Dissemination is of a miliary nature, in a number of cases it can be established only with histological examination. Epithelioid and giant cells of Pirogov-Langhans are practically absent, and instead of a typical case of tuberculosis, coagulation necrosis and suppurative melting are more often observed. In smears-prints from these sites in the majority of observations (72%) show a very large number of mycobacteria tuberculosis, comparable to pure culture. In this regard, in patients in the late stages of HIV infection (4B, 4B and 5) for the timely detection of tuberculosis, morphological and bacteriological examination of biopsy samples is of particular importance.

Also for the diagnosis of tuberculosis and other secondary diseases during this period, it is advisable to apply the PCR method, with the help of which it is possible to detect the genetic material of pathogens in the cerebrospinal fluid, pleural fluid, lavage, biopsy specimens.

The complexity of diagnosis of tuberculosis is determined by the fact. That the majority of patients develop other secondary diseases: candidal stomatitis, visceral candidiasis, recurrent herpes, manifest cytomegalovirus infection caused by HIV encephalopathy, Kaposi's sarcoma, brain toxoplasmosis, pneumocystosis, cryptococcosis, aspergillosis.

The effect of treatment during this period depends on the timely detection of atypically occurring tuberculosis and the appointment of adequate therapy. If tuberculosis is not detected in a timely manner, generalization of the process takes place and treatment is rendered ineffective.

[1], [2], [3], [4]

Identification of tuberculosis in patients with HIV infection

It is recommended immediately after the diagnosis of HIV infection before the development of severe immunodeficiency, to identify patients who are part of the high-risk group of tuberculosis for subsequent follow-up of the phthisiatrician who, in the later stages of HIV infection, when immunodeficiency develops, could prescribe a preventive or primary course of treatment of tuberculosis.

To allocate persons with a high risk of tuberculosis to HIV infection, the following activities are carried out:

• all newly diagnosed patients with HIV infection must be examined by the TB doctor, noting in the outpatient card a detailed history of the increased risk of tuberculosis. The patient is informed of tuberculosis and measures for his prevention and recommends him to report to the TB specialist immediately if there are symptoms characteristic of tuberculosis for an unscheduled examination and examination:
• at once taking on the account and further 1-2 times a year (depending on a degree of risk of disease by a tuberculosis and a stage of a HIV-infection carry out radial diagnostics of organs of a chest cavity (create an x-ray archive on the patient);
• when patients are registered for HIV infection, a tuberculin test (2 TE) is performed, and then, during the period of dynamic observation, it is put 1-2 times a year (depending on the degree of risk of tuberculosis and the stage of HIV infection with the registration of results in the map dispensary observation.

In the period of dynamic observation of patients with HIV infection, if the hypertension, the turn or the reaction to TB tuberculin are detected individually, taking into account the stages of HIV infection and objective data, the question of prescribing the patient with anti-tuberculosis drugs is decided.

At faces. Sputum isolates, conduct its study for the presence of mycobacteria tuberculosis. In case of appearance of clinical or laboratory manifestations of extrapulmonary tuberculosis, if possible, a bacteriological study of the appropriate discharge and / or other indicated methods of examination is carried out.

All patients with HIV infection from the group at risk of tuberculosis, hospitalized in connection with the deterioration of the general condition, must be examined by the phthisiatrician.

Clinical follow-up of patients suffering from HIV infection from the high-risk group of tuberculosis (but without clinical manifestations) is performed by a TB specialist in the screening diagnostic room at the AIDS center. The organization of such a cabinet in an anti-tuberculosis institution will lead to the fact that patients with immunodeficiency will come to the center of tuberculosis infection.

Patients with symptoms of tuberculosis are sent to the office of reference-diagnostics on the basis of an antituberculous dispensary. The essence of the organization of such a cabinet is the presence of a separate entrance to it. Thus, the intersection of epidemiologically dangerous patients with TB and patients from various genesis immunodeficiencies, coming to the TB dispensary for examination, is minimized.

Screening for tuberculosis of patients with HIV infection

In the early stages of HIV infection, tuberculosis has a typical course, so screening during this period is conducted in the same way as in persons without it.

Indications for the extraordinary conduct of tuberculin diagnostics in children are given in Appendix G4 to the Order of the Ministry of Health of Russia dated March 21, 2003 M2 109 "On the improvement of anti-tuberculosis measures in the Russian Federation".

In conditions of developing immunodeficiency in patients with HIV infection, the likelihood of tuberculosis increases, so there is a need to increase the frequency of screening and to introduce additional methods for testing for tuberculosis.

The diagnosis of tuberculosis combined with HIV infection

When detecting tuberculosis in patients with HIV infection, a complete clinical diagnosis should include:

• stage of HIV infection;
• an expanded diagnosis of tuberculosis and other secondary diseases. For example, if a patient with HIV infection in the stage of primary manifestations (it lasts a year since the onset of acute infection or seroconversion) due to a transient decrease in the immune status, tuberculosis develops, then they diagnose: HIV infection. Stage of primary manifestations (PI).

This is followed by an expanded diagnosis of tuberculosis (with the presence or absence of bacterial excretion) and other secondary and subsequent concomitant diseases. The clinical classification of tuberculosis used to formulate his diagnosis is presented in the annex to Order No. 109 of the Ministry of Health of the Russian Federation of March 21, 2003 "On the improvement of anti-tuberculosis measures in the Russian Federation".

If a patient with HIV infection after completion of the stage of primary manifestations and in the absence of any clinical symptoms indicating a deficiency of the immunity system (or laboratory manifestations of immunodeficiency) develops a limited tuberculosis process, it is not advisable to consider it as a secondary disease. In such a case, the diagnosis indicates the latent stage of HIV infection.

Tuberculosis in patients with HIV infection, developed after completion of the stage of primary manifestations, indicates the stage of secondary diseases in the presence of one of the following factors:

• expressed immunodeficiency, confirmed by laboratory methods (CD4 <0.2x10 ⁹ / l) or diagnosed on the basis of clinical manifestations (candidiasis, herpes, etc);
• dissemination of the tuberculosis process;
• a significant decrease in reactivity, recorded in the morphological study of tissues involved in the tubercular process (for example, the lymph node).

Treatment of tuberculosis in patients with HIV infection

Treatment of tuberculosis in patients with HIV infection includes two areas.

• Organization of controlled treatment of tuberculosis in patients with HIV infection.
  • The diagnosis of tuberculosis in patients with HIV infection is confirmed by a phthisiatric TSVKK, which includes a doctor who has completed specialization in HIV infection and who knows the features of tuberculosis in the late stages of HIV infection.
  • Treatment of tuberculosis in patients with HIV infection is carried out in accordance with the standard regimens of tuberculosis therapy approved by the Ministry of Health of Russia, but taking into account the peculiarities of treatment of this pathology in patients with HIV infection.
  • In the course of chemotherapy, medical personnel monitor the intake of antituberculous and antiretroviral drugs by patients
  • After completion of the main course of tuberculosis treatment, dispensary observation of patients continues with a TB specialist specializing in HIV infection, in order to prevent recurrence of the disease.
• Highly active antiretroviral therapy.
• Creation of a system of psychological and social adaptation of patients with tuberculosis, combined with HIV infection.
  • Conducting routine and crisis counseling for patients, their relatives or close psychotherapists of the territorial AIDS center.
  • Before starting treatment, it is necessary to have a conversation with a patient whose goal is to morally support the patient, explain the difference between early and late stages of HIV infection, convince him of the need for immediate long-term treatment in a specialized hospital, focus on the continuation of life in the family, with relatives and friends people, possible work activity. The patient should be informed about the ways of transmission of both infections, measures for their prevention, rules for communicating with sexual partners. In the process of treatment, a patient with tuberculosis and HIV infection should constantly provide psychological support to fix the installation for strict adherence to the treatment regimen, abstinence from taking drugs and alcohol.
  • Comprehensive counseling for the social worker of the territorial AIDS center for patients, their relatives or relatives on issues of employment, housing, various benefits, etc.

The place of inpatient care for patients with tuberculosis, combined with HIV infection, depends on its stage and prevalence in the subject of the Russian Federation.

With a small number of cases of combined pathology in the subject of the Russian Federation, inpatient treatment of patients with tuberculosis in the stage of secondary diseases is carried out by an HIV specialist, but necessarily with the advice of a highly qualified phthisiatrician. This is due to the fact that, in addition to the treatment of tuberculosis in these patients, treatment of HIV infection and the diagnosis and treatment of other secondary diseases are necessary . At the same time, it is necessary to comply with all anti-epidemic measures with regard to tuberculosis infection.

In the early stages of HIV infection (2,3,4A), TB patients are treated by phthisiatricians with mandatory HIV specialist counseling.

In the detection of HIV infection for the first time in patients receiving inpatient treatment in an anti-tuberculosis institution, an epidemiological investigation of the case of HIV infection is required. For this purpose, the center for prevention and control of AIDS in the subject of the Russian Federation, taking into account local conditions, should determine the procedure for conducting it in an anti-tuberculosis facility and specialists responsible for the timeliness and quality of this work.

With a high need for treatment of co-morbidity in the subject of the Russian Federation, a specialized department is created, in the staff of which phthisiatricians and infectious disease doctors are included.

Indications for prescribing antiretroviral therapy

Objectives of highly active antiretroviral therapy (HAART):

• prolongation of life;
• maintenance of quality of life in patients with asymptomatic infection;
• improvement of quality of life in patients with clinical manifestations of secondary diseases;
• prevention of secondary diseases;
• reducing the risk of HIV transmission.

When deciding on the appointment of HAART, inadequate implementation of which involves the risk of forming strains of the virus resistant to drugs, in addition to medical criteria, it is necessary to take into account the socio-psychological, such as the willingness and ability of the patient to undergo the prescribed treatment in full. If necessary, it is necessary to stimulate the patient's interest in therapy (counseling, psychosocial support, etc.). Select the most convenient for him scheme of taking medication. Before the appointment of HAART, the patient signs informed consent.

The presence of HIV infection in itself is not an indication for the appointment of HAART. Too early its appointment is inexpedient, and too late gives the worst results.

Absolute indications;

• clinical: stages 2B, 2B or 4B, 4B in the progression phase;
• laboratory: the amount of CD4 is less than 0.2х10 ⁹ / l. Relative indications:
• Clinical: Stage 4A (regardless of phase). 4B, 4B in the phase of remission;
• LABORATORY: CD4 count equal to 0.2-0.35x10 ⁹ / L, HIV RNA level ("viral load") is more than 100 thousand copies in 1 ml.

If there are relative indications, some experts and guidelines recommend starting therapy, and some - continue to monitor the patient, until he is prescribed treatment. In this situation, the Federal AIDS Research Center recommends. Begin treatment with an active desire of the patient and confidence in his good adherence to treatment, and also if both clinical and laboratory relative indications for therapy take place simultaneously.

The level of CD4 lymphocytes and HIV RNA are taken into account as indications for the appointment of HAART if, within a month before their evaluation, the patient did not have inflammatory diseases and vaccinations.

If the laboratory. Indications for the appointment of HAART are revealed for the first time, and there are no clinical indications for the beginning of therapy, then repeated studies are needed to resolve the issue of treatment:

• with an interval of not less than. 4 weeks at a CD4 level of less than 0.2x10 ⁹ / l;
• with an interval of at least 1.2 weeks with a CD4 count of 0.2-0.35x10 / l.

When appointing HAART for clinical indications, it should be borne in mind that in persons taking psychotropic drugs, fungal and bacterial lesions (skin and mucous membrane lesions, abscesses, phlegmon, pneumonia, endocarditis, sepsis, etc.) often develop not as a consequence of HIV- infection, but as a manifestation of immunodeficiency, associated. With drug use. In these cases, the number of CD4-lymphocytes must be examined for HAART.

Initiation of HAART in most patients is recommended with regimens containing, in addition to two drugs from the group of nucleoside reverse transcriptase inhibitors, HIV. One drug from the group of non-nucleoside reverse transcriptase inhibitors HIV. However, if the patient has HIV infection in stage 4B (progression phase), the CD4-lymphocyte level is less than 0.05 × ^{10 9} / L or the amount of HIV RNA is more than 1 million copies per ml, initiation of therapy is recommended from the regimens containing one preparation from the group of protease inhibitors HIV and two drugs from the group of nucleoside reverse transcriptase inhibitors of HIV.

Active First-line Antiretroviral Therapy Schemes

The recommended first-line HAART regimen:

• efavirenz 0.6 g once a day + zidovudine 0.3 g 2 times or 0.2 g 3 times a day + lamivudine 0.15 g 2 times a day.

For some patients, the standard HAART regimen can not be prescribed (primarily because of the range of side effects of the drugs included in it), in particular:

• Efavirenz is contraindicated in pregnant women and women planning (or not excluding) pregnancy and childbirth on the background of antiretroviral therapy. This drug is not recommended for women capable of childbearing, not using barrier methods of contraception, as well as those working at night;
• zidovudine is not recommended for patients with anemia and granulocytopenia. At a hemoglobin level of less than 80 g / L instead of zidovudine, stavudine may be included in the HAART regimen.

In identifying absolute or relative contraindications to any of the drugs recommended for the standard scheme, it makes a difference.

If a patient has an alanine aminotransferase level corresponding to the 2nd degree of toxicity and more, it is recommended to use HAART regimens with HIV protease inhibitors.

Alternative HAART scheme of the first line:

• lopinavir + ritonavir 0.133 / 0.033 g 3 capsules 2 times a day + zidovudine 0.3 g 2 times or 0.2 g 3 times a day + lamivudine 0.15 g 2 times a day.

Recommended HAART regimen for pregnant women:

• nelfinavir by 1.25 g 2 times a day + zidovudine by 03 g 2 times or by 0.2 g 3 times a day + lamivudine by 0.15 g 2 times a day.

Multiplicity of laboratory studies for assessing the efficacy and safety of HAART:

• the level of HIV RNA and the number of CD4-lymphocytes - 1 and 3 months after the onset of HAART, then 1 time per 3 months;
• a clinical blood test - after 2 weeks. 1 month, 3 months after the onset of HAART, then 1 every 3 months;
• biochemical blood test - 1 and 3 months after the onset of HAART, then 1 time per 3 months;
• in the presence of chronic viral hepatitis - the first study ALT 2 weeks after the start of HAART.

[5], [6], [7], [8], [9], [10], [11], [12], [13]

Features of highly active antiretroviral therapy in patients with tuberculosis

Some experts recommend postponing HAART until the end of taking anti-tuberculosis drugs: in this case, the management of the patient is simplified, both infections are treated according to standard schemes, the side effect of the drugs is not increased. However, in patients with a low CD4 cell count, a delay in initiating HAART can lead to new complications of HIV infection and even death. Therefore, for patients with tuberculosis with a very high risk of progressing HIV infection (with CD4 counts less than 0.2 10 ⁹ / L or generalization of the tuberculosis process), it is recommended not to postpone the onset of HAART.

Adverse events with the use of antituberculosis drugs, as a rule, develop in the first 2 months of treatment. In this regard, it is recommended to start HAART in the interval between 2 weeks and 2 months after the start of antituberculous treatment. Depending on the number of CD4-lymphocytes.

Patients with tuberculosis should be prescribed a primary recommended or alternative HAART regimen.

An alternative to efavirenz can be saquinavir / ritonavir (400/400 mg twice daily or 1600 mg once a day), lopinavir / ritonavir (400/100 mg twice daily), and abacavir (300 mg twice daily) .

Instead of efavirenz, if there are no other alternatives, you can also use nevirapine (200 mg once a day for 2 weeks then 200 mg twice daily) as part of the following regimens: d4T + lamivudine + nevirapine or zidovudine + lamivudine + nevirapine.

[14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24]

Metabolism of HIV protease inhibitors

Rifamycins (rifabutin and rifampicin) induce the activity of cytochrome P450 enzymes, which metabolize non-nucleoside reverse transcriptase inhibitors and HIV protease inhibitors, and hence reduce the serum concentrations of these antiretroviral drugs. In turn, these two groups of antiretroviral drugs through the same mechanism increase the serum concentrations of rifabutin and rifampicin. Thus, drug interactions can lead to ineffective antiretroviral and increased toxicity of antituberculosis drugs. The anti-tuberculosis drug rifabutin can be used in conjunction with all HIV protease inhibitors (except saquinavir) and with all non-nucleoside reverse transcriptase inhibitors. If you periodically adjust its dose.

Tuberculosis and Maternity

Pregnancy and childbirth are accompanied by a reorganization of the functions of the endocrine system, changes in immunity, metabolism and are risk factors for the disease of tuberculosis. The incidence of pregnancy and puerperas is 1.5-2 times higher than the overall incidence of tuberculosis in women. Tuberculosis can develop in any period of pregnancy, but more often in the first 6 months after delivery, tuberculosis that occurs in women during pregnancy and in the postpartum period, usually proceeds more heavily than detected before pregnancy.

Tuberculosis, first emerged during pregnancy

Women who become ill with tuberculosis during pregnancy discover different forms of pulmonary tuberculosis.

Young, previously uninfected women who have undergone primary infection with tubercle bacilli often display primary tuberculosis.

The reactivation of endogenous tuberculosis infection takes place. In this case, disseminated tuberculosis or various forms of secondary tuberculosis is diagnosed. Severe course of the disease with severe tuberculosis intoxication can have an adverse effect on the development of the fetus and lead to spontaneous miscarriage.

In the first trimester of pregnancy, the initial manifestations of tuberculosis, due to moderately severe intoxication (weakness, malaise, decreased appetite, weight loss), are often associated with pregnancy toxicity. In the second half of pregnancy, tuberculosis, in spite of pronounced morphological changes in the lungs, also often occurs without significant clinical symptoms, which significantly complicates its detection.

The development of tuberculosis during pregnancy can be associated with HIV infection. In these cases, tuberculosis lesions are found not only in the lungs, but also in other organs.

Effect of pregnancy on tuberculosis

Exacerbation of tuberculosis during pregnancy does not develop in all women. Tuberculosis is rarely activated in the phases of compaction and calcification, and vice versa, there is a sharp increase or progression in the phases of the active process. Especially severe outbreaks occur in patients with fibrous-cavernous tuberculosis. The first half of pregnancy and the postpartum period are most dangerous for an exacerbation of a tuberculosis. Outbreaks in the postpartum period are especially malignant in nature.

[25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35]

Influence of tuberculosis on the course of pregnancy and childbirth

In severe destructive or disseminated forms of tuberculosis, as a result of intoxication and oxygen deficiency, toxicoses of the first and second halves of pregnancy develop more often, premature births occur more often. In newborns, physiological weight loss is more pronounced and recovery is slower. Timely appointment of specific therapy makes it possible to bring the pregnancy to safe deliveries, to avoid exacerbations of the postpartum period.

Diagnosis of tuberculosis in HIV infection

Tuberculosis in pregnant women is found during examination for complaints of weakness, fatigue, excessive sweating, loss of appetite, weight loss, subfebrile temperature, and cough - dry or with sputum, shortness of breath, chest pain. At occurrence of such complaints the obstetrician-gynecologist of female consultation should direct the patient to an antituberculous dispensary. The Mantoux test with 2 TE PPD-L is performed in the dispensary, blood and urine clinical tests are performed. In the presence of sputum, it is tested on mycobacterium tuberculosis by bacterioscopic and bacteriological methods, in addition - by PCR.

X-ray examination during pregnancy is performed in complex diagnostic situations as an exception, protecting the fetus with a lead shield or apron.

If suspected of tuberculosis or confirmation of the diagnosis, the family members of the pregnant woman are examined.

[36], [37], [38], [39], [40], [41], [42], [43]

Management of pregnancy in a patient with tuberculosis

In most cases, tuberculosis is not the basis for the artificial termination of pregnancy. Complex anti-tuberculosis therapy often allows you to save a pregnancy without harming the health of the mother and child. Pregnancy is usually preserved in patients with active pulmonary tuberculosis without destruction and bacterial excretion, in tuberculous pleurisy, as well as in women who previously without complications suffered surgical interventions for pulmonary tuberculosis.

Indications for abortion in patients with tuberculosis are as follows:

• progressing course of newly diagnosed pulmonary tuberculosis, tuberculous meningitis, miliary tuberculosis:
• fibro-cavernous, disseminated or Cirrhotic pulmonary tuberculosis:
• pulmonary tuberculosis in combination with diabetes mellitus, chronic diseases of other systems and organs with pronounced functional impairment (pulmonary-cardiac, cardiovascular, renal failure);
• tuberculosis of the lungs, which requires surgical intervention.

Interrupt pregnancy should be with the consent of a woman during the first 12 weeks. During preparation and after termination of pregnancy, it is necessary to strengthen anti-tuberculosis therapy. Repeated pregnancy is recommended not earlier than in 2-3 years.

Pregnant women with an established diagnosis of tuberculosis are registered and are monitored by the district phthisiatrician and obstetrician-gynecologist. If a progressive tuberculoma, cavernous or fibrous-cavernous tuberculosis with bacterial excision is detected in a pregnant woman, the possibility of an operative intervention on the lung with the purpose of rapid cessation of bacterial excretion is not ruled out.

For delivery, a woman with tuberculosis is sent to a special maternity hospital. If there is no such maternity hospital. The obstetrician-gynecologist and phthisiatrician must inform the maternity ward in advance to conduct organizational measures that exclude the patient from contacting healthy mothers. Labor in patients with active tuberculosis often occurs more severely than in healthy women, with more blood loss and other complications. With pulmonary tuberculosis with pulmonary-cardiac insufficiency, in the presence of artificial pneumothorax, surgical delivery by caesarean section is expedient.

Intrauterine infection of the fetus with mycobacterium tuberculosis is rare, the mechanisms of such infection are hematogenous through the umbilical vein or aspiration with infected amniotic fluid. After birth, the contact of a child with a tuberculosis patient with a mother in terms of primary infection with mycobacterium tuberculosis and tuberculosis is very dangerous.

Management of newborns for tuberculosis and HIV infection

Maintaining a child born from a mother with tuberculosis:

• If the pregnant woman is sick with active tuberculosis, irrespective of the allocation of mycobacterium tuberculosis, the following measures are taken:
  • doctors of the maternity ward are informed in advance of the presence of tuberculosis in the mother;
  • The mother is placed in a separate box;
  • immediately after the birth of the child is isolated from the mother;
  • transfer the child to artificial feeding;
  • the child is vaccinated with BCG;
  • the child is separated from the mother for the period of immunity formation - not less than 8 weeks (the child is sent home to relatives or placed under indications in a specialized department);
  • in the presence of contraindications to vaccination or the impossibility of separation, the child is chemoprophylaxis;
  • Before discharge, a survey of the future environment of the child is carried out;
  • before discharge, disinfect all rooms;
  • the mother is hospitalized for treatment.
• If the child before the introduction of the BCG vaccine was in contact with the mother (birth of a child outside the medical facility, etc.). Carry out the following activities:
  • the mother is hospitalized for treatment, the child is isolated from the mother,
  • vaccination against tuberculosis is not carried out,
  • the child is prescribed a course of chemoprophylaxis for 3 months;
  • after chemoprophylaxis Mantoux reaction with 2 TE;
  • with negative Mantoux reaction with 2 TE, vaccination with BCG-M is carried out;
  • After vaccination, the child remains separated from the mother for at least 8 weeks.
• If the presence of tuberculosis in the mother was not known to the tuberculosis dispensary and the detection of tuberculosis occurred after the introduction of the BCG vaccine to the child, the following measures are taken:
  • the child is separated from the mother;
  • the child is given preventive treatment regardless of the timing of the introduction of the BCG vaccine;
  • such children are under close supervision in the TB dispensary as the most endangered risk group for tuberculosis.

Rodilnitsa 1-2 days after the birth of an X-ray examination of the lungs and taking into account the bacteriological data determine the further tactics regarding the possibilities of breastfeeding and the necessary treatment.

Breastfeeding of newborns is allowed only to mothers with inactive tuberculosis, which does not secrete mycobacterium tuberculosis. The mother at this time should not take anti-TB drugs, so as not to affect the formation of immunity after the vaccination of the child BCG.

Treatment of tuberculosis in pregnant women with HIV infection

Treatment of tuberculosis in pregnant women, as well as in nursing mothers, is carried out in accordance with standard regimens of chemotherapy and individualization of medical tactics. When choosing drugs, you need to consider:

• possible side reactions to aminosalicylic acid and ethionamide in the form of dyspeptic disorders, therefore they should not be prescribed in case of toxicosis of pregnancy;
• embryotoxic effect of streptomycin and kanamycin, which can cause deafness in children whose mothers have been treated with these drugs;
• possible teratogenic effect of ethambutol, ethionamide.

The least dangerous for the pregnant and fetus is isoniazid. It should be prescribed for treatment and for the prevention of exacerbations of tuberculosis.