Tuberculosis in HIV infection

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

Clinical classification of HIV infection

1. Incubation stage.
2. Stage of primary manifestations.

Flow options

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

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

4A. Weight loss less than 10%. Fungal, viral, bacterial lesions of the skin and mucous membranes, recurrent pharyngitis, sinusitis, shingles.

Phases.

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

4B. Cachexia. Generalized viral, bacterial, mycobacterial, fungal, protozoal, parasitic diseases, including: candidiasis of the esophagus, bronchi, trachea, lungs; Pneumocystis pneumonia; malignant tumors; CNS lesions.

Phases.

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

5. Terminal stage.

During the incubation stage of HIV infection, before seroconversion, the virus actively multiplies, which often leads to immunodeficiency. In conditions of a decrease in the body's immune response, tuberculosis may develop in those infected with mycobacteria during this period, which is often regarded as a manifestation of the late stages of HIV infection (stages 4B, 4C and 5). As a result, the prognosis is erroneously determined and treatment and dispensary observation are prescribed that do not correspond to these stages.

The onset of the primary manifestation stage, occurring in the form of acute infection, is most often noted in the first 3 months after infection. It may precede seroconversion (the appearance of antibodies to HIV in the blood), therefore, in patients with tuberculosis who belong to the high-risk group for HIV infection, a repeat examination is advisable after 2-3 months. The clinical manifestations of tuberculosis at this stage of HIV infection do not differ from those in patients not infected with HIV.

Long-term observation of patients who have had tuberculosis at the stage of primary manifestations shows that after a transient decrease in the immune status, it is restored and the usual treatment of tuberculosis produces a good effect. After completion of the main course of treatment, the general condition of patients often remains satisfactory for many years: there are no relapses of tuberculosis, the immune status does not undergo significant changes, and no other secondary diseases arise. HIV infection during this period can bring additional clinical manifestations that need to be differentiated from tuberculosis: enlarged lymph nodes, liver, 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 the peripheral lymph nodes. In persistent generalized lymphadenopathy, the lymph nodes are usually elastic, painless, not fused with the surrounding tissue, and the skin above 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 body of a person infected with HIV, the compensatory capabilities of the immune system at the end of the latent stage are reduced and severe immunodeficiency develops. The probability of developing tuberculosis increases again, and the more severe the immunodeficiency becomes, the more tissue reactions to the tuberculosis pathogen change: productive reactions are lost, alternative reactions with dissemination of the pathogen increasingly predominate.

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

In patients at stage 4B, which usually develops 6-10 years after HIV infection, the radiographic picture increasingly takes on atypical features.

In stage 4B, even more pronounced deviations from the typical tuberculosis manifestations appear, the process is characterized by generalization, often with a complete absence of changes on chest X-rays. Against the background of significant immunodeficiency, other secondary diseases develop, which further complicates the diagnosis of tuberculosis.

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

Often, a radiological triad is determined: bilateral focal or focal dissemination, an increase in three or more groups of intrathoracic lymph nodes, exudative pleurisy, while rapid dynamics of changes in the radiological picture are possible both in the positive and negative direction. Cavities of decay 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 the background of severe immunodeficiency.

A vivid clinical picture may precede the appearance of dissemination by 4-14 weeks. In some patients, no changes can be detected on the radiograph at all. Among the clinical manifestations, the most common are symptoms of severe intoxication: severe sweating, temperature increases up to 39 ^o C. In some cases, patients are bothered by a painful cough with very scanty sputum; it may also be absent. Cachexia is detected in a third of patients.

The percentage of bacteria excretors 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 cases of tuberculosis in the decay phase during this period. Tuberculin tests in the "late" stages of HIV infection are in most cases uninformative.

During pathomorphological examination of removed lymph nodes, massive conglomerates with total caseation are often identified.

Morphological examination mainly records alterative reactions (necrosis) - 76%. Dissemination is miliary in nature, in some cases it can be established only by histological examination. Epithelioid and giant Pirogov-Langhans cells are practically absent, and instead of caseation typical for tuberculosis, coagulation necrosis and purulent melting are more often observed. In smears-prints from these areas in most observations (72%) a very large number of mycobacteria tuberculosis is found, comparable to a pure culture. In this regard, in patients in the late stages of HIV infection (4B, 4C and 5), morphological and bacteriological examination of biopsy specimens is of particular importance for the timely detection of tuberculosis.

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

The difficulty of diagnosing tuberculosis is also due to the fact that most patients develop other secondary diseases: candidal stomatitis, visceral candidiasis, recurrent herpes, manifest cytomegalovirus infection, HIV-induced encephalopathy, Kaposi's sarcoma, toxoplasmosis of the brain, pneumocystosis, cryptococcosis, aspergillosis.

The effect of treatment during this period depends on the timeliness of detection of atypical tuberculosis and the appointment of adequate therapy. If tuberculosis is not detected in time, the process becomes generalized and treatment is ineffective.

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Detection of tuberculosis in patients with HIV infection

It is recommended that immediately after the diagnosis of HIV infection, before the development of severe immunodeficiency, patients who are at high risk of developing tuberculosis be identified for subsequent dynamic monitoring by a phthisiatrician, who in the late stages of HIV infection, when immunodeficiency develops, could promptly prescribe a preventive or primary course of treatment for tuberculosis.

To identify individuals with a high risk of developing tuberculosis against the background of HIV infection, the following measures are taken:

• All newly diagnosed patients with HIV infection are necessarily examined by a phthisiatrician, who notes in the outpatient card a detailed anamnesis regarding the increased risk of tuberculosis. The patient is informed about tuberculosis and measures for its prevention and is recommended to immediately visit a phthisiatrician for an unscheduled examination and testing if symptoms characteristic of tuberculosis appear:
• immediately upon registration and then 1-2 times a year (depending on the degree of risk of tuberculosis and the stage of HIV infection, radiological diagnostics of the chest organs is carried out (an X-ray archive is created for the patient);
• When registering patients for HIV infection, a tuberculin test (2 TE) is performed, and then during the period of dynamic observation it is performed 1-2 times a year (depending on the degree of risk of tuberculosis and the stage of HIV infection with the results recorded in the dispensary observation card.

During the period of dynamic observation of patients with HIV infection, when hyperergy, a turn or an increase in the reaction to tuberculin is detected, the phthisiatrician, on an individual basis, taking into account the stages of HIV infection and objective data, decides on the issue of prescribing anti-tuberculosis drugs to the patient.

In individuals producing sputum, it is examined for the presence of Mycobacterium tuberculosis. In the event of clinical or laboratory manifestations of extrapulmonary tuberculosis, if possible, a bacteriological examination of the corresponding discharge and/or other indicated examination methods are performed.

All patients with HIV infection from the risk group for tuberculosis, hospitalized due to deterioration of their general condition, must be examined by a phthisiatrician.

Outpatient observation of patients suffering from HIV infection from the high-risk group for tuberculosis (but without clinical manifestations) is carried out by a phthisiatrician in the screening diagnostics room at the AIDS center. The organization of such a room in an anti-tuberculosis institution will lead to the fact that patients with immunodeficiency will come to the center of tuberculosis infection.

Patients with tuberculosis symptoms are sent to the reference diagnostics room at the tuberculosis dispensary. The essence of organizing such a room is the presence of a separate entrance to it. Thus, the intersection of epidemiologically dangerous tuberculosis patients and patients with various genesis of immunodeficiencies coming to the tuberculosis dispensary for examination is minimized.

Screening examination for tuberculosis in patients with HIV infection

In the early stages of HIV infection, tuberculosis has a typical course, so screening examination during this period is carried out in the same way as for people without it.

Indications for unscheduled 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 improving anti-tuberculosis measures in the Russian Federation”.

In conditions of the beginning development of immunodeficiency in patients with HIV infection, the probability of tuberculosis increases, in connection with this there is a need to increase the frequency of screening examinations and to introduce additional methods of examination for tuberculosis.

Formulation of diagnosis for tuberculosis combined with HIV infection

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

• stage of HIV infection;
• detailed 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 from the onset of acute infection or seroconversion) develops tuberculosis due to a transient decrease in immune status, then the diagnosis is: HIV infection. stage of primary manifestations (PV).

This is followed by a detailed diagnosis of tuberculosis (with the presence or absence of bacterial excretion noted) and other secondary and then concomitant diseases. The clinical classification of tuberculosis used to formulate its diagnosis is presented in the appendix to the Order of the Ministry of Health of Russia dated March 21, 2003, No. 109 "On improving anti-tuberculosis measures in the Russian Federation."

If a patient with HIV infection develops a limited tuberculosis process after the completion of the primary manifestations stage and in the absence of any clinical symptoms indicating the insufficiency of the immune system (or laboratory manifestations of immunodeficiency), it is inappropriate to consider it as a secondary disease. In such a case, the latent stage of HIV infection is indicated in the diagnosis.

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

• severe 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 during morphological examination of tissues involved in the tuberculosis process (for example, a lymph node).

Treatment of tuberculosis in patients with HIV infection

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

• Organization of controlled treatment of tuberculosis in patients with HIV infection.
  • The diagnosis of tuberculosis in patients with HIV infection is confirmed by the phthisiological CVK, which includes a physician who has specialized in HIV infection and is familiar with the characteristics of the course of tuberculosis in the late stages of HIV infection.
  • Treatment of tuberculosis in patients with HIV infection is carried out in accordance with standard tuberculosis therapy regimens approved by the Russian Ministry of Health, but taking into account the specifics of treating this pathology in patients with HIV infection.
  • During chemotherapy, medical staff monitor the intake of anti-tuberculosis and antiretroviral drugs by patients.
  • After completion of the main course of treatment for tuberculosis, dispensary observation of patients is continued by a phthisiatrician who specializes in HIV infection in order to prevent relapse 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 planned and crisis counseling for patients, their relatives or loved ones by a psychotherapist of the territorial AIDS center.
  • Before starting treatment, it is necessary to have a conversation with the patient, the purpose of which is to provide moral support to the patient, explain the difference between the early and late stages of HIV infection, convince him of the need for immediate long-term treatment in a specialized hospital, orient him towards continuing life in the family, with relatives and close people, possible work activity. The patient must be informed about the ways of transmission of both infections, measures for their prevention, rules of communication with sexual partners. During the treatment, the patient with tuberculosis and HIV infection must be constantly provided with psychological support in order to reinforce the attitude towards strict adherence to the treatment regimen, abstinence from drugs and alcohol.
  • Comprehensive advisory assistance from a social worker of the territorial AIDS center to patients, their relatives or loved ones on issues of employment, housing, various benefits, etc.

The location of inpatient care for patients with tuberculosis combined with HIV infection depends on its stage and prevalence in the constituent entity of the Russian Federation.

In a small number of cases of combined pathology in a subject of the Russian Federation, inpatient treatment of patients with tuberculosis in the stage of secondary diseases is carried out by a specialist in HIV infection, but necessarily with the advisory assistance 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 diagnosis and treatment of other secondary diseases are necessary. At the same time, it is necessary to observe all anti-epidemic measures in relation to tuberculosis infection.

In the early stages of HIV infection (2,3,4A), treatment of these patients is carried out by phthisiatricians with mandatory consultations with an HIV specialist.

When HIV infection is detected for the first time in patients receiving inpatient treatment in a tuberculosis facility, it is necessary to conduct an epidemiological investigation of the HIV infection case. For this purpose, the center for the prevention and control of AIDS in the constituent entity of the Russian Federation, taking into account local conditions, must determine the procedure for conducting it in the tuberculosis facility and the specialists responsible for the timeliness and quality of this work.

If there is a high need for treatment of combined pathology in a constituent entity of the Russian Federation, a specialized department is created, the staff of which includes phthisiologists and infectious disease specialists.

Indications for antiretroviral therapy

Goals of highly active antiretroviral therapy (HAART):

• life extension;
• maintaining quality of life in patients with asymptomatic infection;
• improving the quality of life in patients with clinical manifestations of secondary diseases;
• prevention of development of secondary diseases;
• reducing the risk of HIV transmission.

When deciding on the appointment of HAART, the inadequate implementation of which is associated with the risk of the formation of drug-resistant virus strains, in addition to medical criteria, it is necessary to take into account socio-psychological criteria, such as the patient's readiness and ability 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 drug regimen for him. Before prescribing HAART, the patient signs an informed consent.

The presence of HIV infection in itself is not an indication for the prescription of HAART. Prescribing it too early is inappropriate, and prescribing it too late gives worse results.

Absolute readings;

• clinical: stages 2B, 2C or 4B, 4C in the progression phase;
• laboratory: CD4 count less than 0.2x10 ⁹ /l. Relative readings:
• clinical: stages 4A (regardless of phase). 4B, 4C in the remission phase;
• .laboratory: CD4 count equal to 0.2-0.35x10 ⁹ /l, HIV RNA level (“viral load”) more than 100 thousand copies in 1 ml.

In the presence of relative indications, some experts and guidelines recommend starting therapy, while others recommend continuing to monitor the patient without prescribing treatment. In this situation, the Federal Scientific and Methodological Center for AIDS recommends starting treatment with the patient's active desire and confidence in his good adherence to treatment, as well as if both clinical and laboratory relative indications for therapy are present at the same time.

The level of CD4 lymphocytes and HIV RNA are taken into account as indications for the appointment of HAART if the patient has not had any diseases accompanied by inflammatory processes or vaccinations within a month prior to their assessment.

If laboratory indications for the appointment of HAART are identified for the first time, and there are no clinical indications for the start of therapy, then repeated studies are necessary to decide on the treatment:

• at intervals of at least 4 weeks with CD4 levels less than 0.2x10 ⁹ /l;
• at intervals of at least 1.2 weeks with a CD4 count of 0.2-0.35x10 /l.

When prescribing HAART for clinical indications, it should be taken into account that in individuals taking psychotropic drugs, fungal and bacterial lesions (lesions of the skin and mucous membranes, 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, to prescribe HAART, it is necessary to examine the number of CD4 lymphocytes.

In most patients, it is recommended to start HAART with regimens containing, in addition to two drugs from the group of nucleoside HIV reverse transcriptase inhibitors, one drug from the group of non-nucleoside HIV reverse transcriptase inhibitors. However, if the patient has HIV infection at stage 4B (progression phase) with a CD4 lymphocyte level of less than 0.05x10 ⁹ /l or an HIV RNA count of more than 1 million copies in 1 ml, it is recommended to start therapy with regimens containing one drug from the group of HIV protease inhibitors and two drugs from the group of nucleoside HIV reverse transcriptase inhibitors.

First-line active antiretroviral therapy regimens

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 cannot be prescribed (primarily due to the range of side effects of the drugs included in it), in particular:

• Efavirenz is contraindicated in pregnant women and women planning (or considering) pregnancy and childbirth while receiving antiretroviral therapy. This drug is not recommended for women of childbearing potential who are not using barrier methods of contraception, as well as for people who work at night;
• Zidovudine is not recommended for patients with anemia and granulocytopenia. If the hemoglobin level is less than 80 g/l, stavudine can be included in the HAART regimen instead of zidovudine.

If absolute or relative contraindications to any of the drugs recommended for the standard regimen are identified, changes are made to it.

If the patient has a level of alanine aminotransferase corresponding to grade 2 toxicity or higher, it is recommended to use HAART regimens with HIV protease inhibitors.

Alternative first-line HAART regimen:

• 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 1.25 g 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.

Frequency of laboratory tests to assess the effectiveness and safety of HAART:

• HIV RNA level and CD4 lymphocyte count - 1 and 3 months after the start of HAART, then once every 3 months;
• clinical blood test - 2 weeks, 1 month, 3 months after the start of HAART, then once every 3 months;
• biochemical blood test - 1 and 3 months after the start of HAART, then once every 3 months;
• in the presence of chronic viral hepatitis - the first ALT test 2 weeks after the start of HAART.

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Features of highly active antiretroviral therapy in patients with tuberculosis

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

Adverse events with anti-tuberculosis drugs usually develop in the first 2 months of treatment. In this regard, it is recommended to start HAART between 2 weeks and 2 months after the start of anti-tuberculosis treatment. depending on the number of CD4 lymphocytes.

Patients with tuberculosis should be prescribed the main recommended or alternative HAART regimen.

Alternatives to efavirenz include saquinavir/ritonavir (400/400 mg twice daily or 1600/200 mg once daily), lopinavir/ritonavir (400/100 mg twice daily), and abacavir (300 mg twice daily).

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

[ 8 ], [ 9 ], [ 10 ], [ 11 ], [ 12 ], [ 13 ], [ 14 ], [ 15 ], [ 16 ]

Metabolism of HIV protease inhibitors

Rifamycins (rifabutin and rifampicin) induce the activity of cytochrome P450 enzymes that metabolize non-nucleoside reverse transcriptase inhibitors and HIV protease inhibitors, and therefore reduce serum concentrations of these antiretroviral drugs. In turn, these two groups of antiretroviral drugs increase serum concentrations of rifabutin and rifampicin through the same mechanism. Thus, drug interactions can lead to the ineffectiveness of antiretroviral drugs and increased toxicity of antituberculosis drugs. The antituberculosis drug rifabutin can be used in combination with all HIV protease inhibitors (except saquinavir) and all non-nucleoside HIV reverse transcriptase inhibitors. if its dose is adjusted periodically.

Tuberculosis and motherhood

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

Tuberculosis that first appeared during pregnancy

Women who develop tuberculosis during pregnancy develop various forms of pulmonary tuberculosis.

In young, previously uninfected women who are exposed to primary infection with Mycobacterium tuberculosis, primary tuberculosis is often detected.

More often, reactivation of endogenous tuberculosis infection occurs. In this case, disseminated tuberculosis or various forms of secondary tuberculosis are diagnosed. Severe course of the disease with pronounced tuberculosis intoxication can have an adverse effect on fetal development and lead to spontaneous abortion.

In the first trimester of pregnancy, the initial manifestations of tuberculosis, caused by moderate intoxication (weakness, malaise, loss of appetite, weight loss), are often associated with toxicosis of pregnancy. In the second half of pregnancy, tuberculosis, despite pronounced morphological changes in the lungs, also often occurs without pronounced clinical symptoms, which significantly complicates its detection.

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

The Impact of Pregnancy on Tuberculosis

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

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The impact of tuberculosis on the course of pregnancy and childbirth

In severe destructive or disseminated forms of tuberculosis, toxicosis of the first and second halves of pregnancy often develops as a result of intoxication and oxygen deficiency, and premature births often occur. Newborns experience a greater physiological decrease in body weight and its restoration is slower. Timely administration of specific therapy allows the pregnancy to be brought to a successful birth, and exacerbations of the postpartum period to be avoided.

Diagnosis of tuberculosis in HIV infection

Tuberculosis in pregnant women is detected during examination for complaints of weakness, fatigue, excessive sweating, loss of appetite, weight loss, subfebrile temperature, as well as cough - dry or with sputum, shortness of breath, chest pain. If such complaints appear, the obstetrician-gynecologist of the antenatal clinic should refer the patient to the anti-tuberculosis dispensary. In the dispensary, the Mantoux test with 2 TE PPD-L is performed, clinical blood and urine tests are performed. If sputum is present, it is examined for Mycobacterium tuberculosis using bacterioscopic and bacteriological methods, additionally - using 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 tuberculosis is suspected or the diagnosis is confirmed, members of the pregnant woman’s family are examined.

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Pregnancy management in a patient with tuberculosis

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

Indications for termination of pregnancy in patients with tuberculosis are as follows:

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

Pregnancy should be terminated with the woman's consent during the first 12 weeks. During the period of preparation and after the termination of pregnancy, it is necessary to intensify anti-tuberculosis therapy. A repeat pregnancy is recommended no earlier than after 2-3 years.

Pregnant women with a confirmed diagnosis of tuberculosis are registered and monitored by a local phthisiatrician and obstetrician-gynecologist. If a pregnant woman is diagnosed with progressive tuberculoma, cavernous or fibro-cavernous tuberculosis with bacterial excretion, the possibility of surgical intervention on the lung in order to quickly stop bacterial excretion cannot be ruled out.

For childbirth, a woman with tuberculosis is sent to a special maternity hospital. If there is no such maternity hospital, the obstetrician-gynecologist and phthisiologist must notify the maternity ward in advance to implement organizational measures to prevent the patient from coming into contact with healthy women in labor. Childbirth in patients with active tuberculosis is often more difficult than in healthy women, with greater blood loss and other complications. In case of pulmonary tuberculosis with pulmonary-cardiac insufficiency, in the presence of artificial pneumothorax, surgical delivery by cesarean section is advisable.

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

Management of newborns with tuberculosis and HIV infection

Care of a child born to a mother with tuberculosis:

• If a pregnant woman has active tuberculosis, regardless of the isolation of Mycobacterium tuberculosis, the following measures are taken:
  • doctors in the maternity ward are notified in advance about the presence of tuberculosis in the mother in labor;
  • the woman in labor is placed in a separate box;
  • immediately after birth 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 - at least 8 weeks (the child is discharged home to relatives or placed in a specialized department, if indicated);
  • if there are contraindications to vaccination or if isolation is impossible, the child is given chemoprophylaxis;
  • Before discharge, an examination of the child's future environment is carried out;
  • Before discharge, all premises are disinfected;
  • The mother is hospitalized for treatment.
• If the child was in contact with the mother before the BCG vaccine was administered (child was born outside a medical facility, etc.), the following measures are taken:
  • 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, the Mantoux test with 2 TE is performed;
  • in case of a negative Mantoux reaction with 2 TE, BCG-M vaccination is carried out;
  • After vaccination, the child remains separated from the mother for at least 8 weeks.
• If the tuberculosis dispensary was not aware of the mother’s tuberculosis and tuberculosis was detected after the child was given the BCG vaccine, the following measures are taken:
  • the child is separated from the mother;
  • the child is prescribed preventive treatment regardless of the timing of the BCG vaccine administration;
  • Such children are under close observation in the tuberculosis dispensary as the most at-risk group for developing tuberculosis.

The mother undergoes an X-ray examination of the lungs 1-2 days after birth and, taking into account the bacteriological data, further tactics are determined regarding the possibility of breastfeeding and the necessary treatment.

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

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 chemotherapy regimens and individualization of treatment tactics. When choosing drugs, it is necessary to consider:

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

The least dangerous for the pregnant woman and the fetus is isoniazid. It should be prescribed for therapeutic purposes and to prevent exacerbations of tuberculosis.