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FREQUENCY OF MYCOSES IN PATIENTS WITH DRUG-RESISTANT PULMONARY
TUBERCULOSIS
Kenzhaeva Nozima Akhtamovna
Bukhara State Medical Institute, Department of Phthisiology and Pulmonology
Kenjayeva.nozima@bsmi.uz
Actuality:
One of the current problems of phthisiology is the high incidence of tuberculosis
among HIV-infected patients. The prevalence of these diseases in the same population groups
causes their frequent association with each other, which makes the prognosis of combined
pathology extremely unfavorable.
The emergence of multiple drug resistance in Mycobacterium tuberculosis has become a serious
threat to the effectiveness of anti-tuberculosis programs in many countries of the world [ 1] . The
growth of the HIV epidemic is also reflected in the situation with drug-resistant tuberculosis,
which is also associated with impaired anti-tuberculosis immunity [4]. The high frequency of
multiple drug resistance in Mycobacterium tuberculosis (resistance to the most effective anti-
tuberculosis drugs isoniazid and rifampicin ) clearly and directly correlates with the prevalence
of HIV infection [3]. Drug resistance in Mycobacterium tuberculosis is one of the main factors
limiting the effectiveness of anti-tuberculosis therapy.
The prevalence of resistant forms of Mycobacterium tuberculosis in newly diagnosed patients
with tuberculosis and HIV infection is higher than in patients with tuberculosis without HIV
infection (2% versus 0.4%).
Key words:
tuberculosis, mycoses, HIV patients, frequency
According to WHO data, in 2006 there were already about half a million cases of tuberculosis
with multiple drug resistance (MDR) of Mycobacterium tuberculosis on the planet, accounting
for 5.3% of all cases of tuberculosis. In 2006 alone, more than 23 thousand new cases with
multiple drug resistance were identified [7].
The recommended treatment regimens for both drug-sensitive and drug-resistant tuberculosis
remain the same regardless of whether the patient is HIV-infected. However, treatment of
tuberculosis in HIV-infected patients is often more difficult, and adverse reactions occur more
frequently.
Patients with multi-resistant forms of tuberculosis are epidemiologically more dangerous due to
the high virulence of mycobacterium tuberculosis, longer duration of bacterial excretion , high
level of contagiousness , especially for HIV-infected individuals. This category of patients
largely determines the level of disability and mortality from tuberculosis [7].
Important and necessary areas in the phthisiology clinic are diagnostics of various opportunistic
fungal infections. Patients with pulmonary tuberculosis are classified as a risk group for the
development of secondary pneumomycosis, which is determined by the course of the
tuberculosis process itself and the presence of a number of predisposing factors: HIV infection,
long-term use of combinations of chemotherapeutic drugs, including broad-spectrum antibiotics,
an increase in the number of invasive procedures, the presence of cavities in the patient's lungs,
etc. To date, more than 50 species of fungi of different taxonomic groups and physiological
properties have been isolated from AIDS patients. Risk factors for the development of fungal
infections of the bronchi and lungs also include colonization of the mucous membranes of the
lower respiratory tract by opportunistic fungi. The spectrum of pathogens of mycosis is rapidly
expanding; more than 400 species of fungi are currently known to cause diseases in humans.
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The most common pathogens of mycoses are yeast-like fungi of the genus Candida and mycelial ,
mold fungi of the genera Aspergillus , Penicillium , Mucor and some others. The risk of
developing candidiasis in HIV-infected people increases with the progression of
immunodeficiency.
Almost 20 years before the first case of AIDS was described, it was noted that Candida albicans
may mark the earliest stages of immunodeficiency, which are detected only by modern
laboratory tests. In 1984, when methods for laboratory confirmation of HIV infection had not yet
been developed, Klein RS and co-authors indicated that oral candidiasis was an important sign
that heralded the development of AIDS. Due to the significant increase in HIV infection, fungal
invasions began to occur more and more often. In HIV-infected people, the frequency of carriage
of candida in the oral cavity reaches 80%, while in practically healthy people it is 46-51%.
Since HIV-infected individuals usually had a cellular-functional "imbalance" of the immune
system, they were diagnosed with diseases caused by aspergilli, penicillium , mucor and other
fungi. In recent years, aspergillosis has become a pressing problem in individuals with various
immunodeficiencies. In particular, 20% of such patients develop mycoses, and among the latter,
more than 70% are aspergillosis. Infections of HIV-infected patients with dust containing
aspergilli (airborne dust transmission of infection) are observed.
Patients with candidiasis and tuberculosis against the background of HIV infection usually suffer
from profound damage to T-cell immunity, when the number of CD-4 lymphocytes fluctuates
from 50 to 70 in 1 μl . The more pronounced the immunodeficiency, the more pronounced the
manifestations of candidiasis.
1.
1. Features of the course of tuberculosis against the background of HIV infection.
Tuberculosis in patients with HIV infection is a global problem: tuberculosis is the main cause of
death in patients with HIV infection. It is known that the same social groups of the population:
the unemployed, migrants, drug addicts, persons in and arriving from places of imprisonment are
at risk of contracting tuberculosis and can be infected with HIV [13].
The HIV epidemic remains largely uncontrolled, despite intensive efforts by researchers, doctors,
and health care providers. Significant progress has been made, including in the area of treatment,
but for every 2 patients receiving antiretroviral therapy (ART), there are 5 new HIV-infected
people.
The course, diagnosis and treatment effectiveness of tuberculosis depend on the stage of HIV
infection. In the early stages of HIV infection, the course of tuberculosis does not differ from that
in individuals without HIV infection, whereas in the late stages, tuberculosis acquires atypical
clinical, radiological and morphological features, which causes significant diagnostic difficulties.
The frequency of generalized forms of tuberculosis in the late stages of HIV infection is high.
Conflicting data on the frequency of bacilli excretion , the presence of other secondary infections
in this category of patients require modern comprehensive diagnostics ( biopsy , radiation,
molecular). Standard short-term treatment regimens for tuberculosis in patients with HIV
infection are often ineffective, so the duration of treatment for such patients should be at least 9
months [16]. The most important aspect is the combined (anti-tuberculosis and antiretroviral)
therapy of patients with tuberculosis and HIV infection [15].
The growth of AIDS and tuberculosis epidemics, leading to persistent disability and premature
mortality, is a priority problem for the global community. Mortality from tuberculosis remains
high, and mortality from HIV/AIDS continues to grow. A number of studies have noted that
despite the initially good clinical response to therapy, the prognosis for tuberculosis patients with
HIV infection remains unfavorable [10].
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Recently, the number of tuberculosis patients who are simultaneously infected with HIV has
been increasing: tuberculosis is diagnosed in 5-15% of HIV-infected patients. For Uzbekistan,
the problem of tuberculosis in HIV-infected patients is of particular importance, since the high
infection rate of the entire population with tuberculosis mycobacteria and the rapid spread of
HIV infection in the high-risk group make the prognosis for this combined pathology
unfavorable.
The fight against it is significantly complicated by the fact that there is a mutually aggravating
synergy between tuberculosis and HIV: HIV infection promotes the progression of tuberculosis
infection, and tuberculosis worsens the course of HIV infection.
Since the start of the epidemic and until 2009, HIV has infected almost 60 million people
worldwide and 25 million people have died from HIV-related illnesses. In 2008, there were
about 33.4 million people living with HIV, about 2.7 million new HIV cases and 2 million
people died from AIDS-related illnesses.
Tuberculosis is the leading cause of death among people living with HIV. In 2008, WHO
reported the highest increase in multidrug-resistant tuberculosis (MDR-TB). 5% of all TB cases
are caused by MDR-TB. 8 million deaths were averted in 2008 using the direct-observed
treatment strategy (DOTS).
UN Secretary-General Ban Ki-moon, in his message for World AIDS Day 2009, said: "We must
keep doing what works , but we must also urgently do more to ensure that by 2010 we deliver on
our commitment that everyone should have access to prevention, treatment, care and support."
Mycoses against the background of HIV/TB. In our country, over the past 30 years, there has
been a significant increase in the number of diseases caused by yeast-like fungi of the genus
Candida . They affect the mucous membranes and lead to severe disseminated forms with the
involvement of the lungs, gastrointestinal tract, urinary and genital systems in the pathological
process; cases of candidal sepsis and meningitis [12].
In recent decades, there has also been a significant increase in fungal diseases, both superficial
and severe visceral mycoses, associated with HIV infection. This is due to many factors and, in
particular, to the widespread use of broad-spectrum antibiotics, immunosuppressants and other
groups of drugs in medical practice, the development of resistance of pathogens to existing drugs
().
Mycoses are opportunistic diseases caused by parasitic fungi that occur mainly in patients with
local or general immune impairment or immunodeficiency.
biquitous M , i.e. those that are widespread (for example, actinomycosis, candidiasis,
trichophytosis), and endemic M, i.e. those that have areas of distribution (for example, keloid
blastomycosis, characteristic of South America).
Mycocenoses , associations of pathogens, are increasingly important in the emergence of M. A
distinction is made between mixed ( fungal -fungal) and combined ( fungal -bacterial, fungal -
parasitic, etc.) mycocenoses .
According to Khamdamova G. T. et al. , 2005, candidiasis is detected in 82.0% of cases in
patients with HIV and tuberculosis. A feature of the clinical picture of candidiasis in HIV-
infected patients is the high frequency of lesions of the oropharynx and esophagus in the absence
of lesions of the skin and nails.
Meanwhile, at present, insufficient attention is paid to the early detection and timely
treatment of mycoses of the bronchopulmonary system in HIV-infected patients with
tuberculosis.
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In this regard, the study of the incidence, clinical manifestations and treatment of
mycoses of the bronchopulmonary system in patients with HIV/AIDS infection receiving anti-
tuberculosis drugs is an urgent task for phthisiology.
According to WHO, one fifth of the world's population suffers from or has suffered at least once
from various forms of candidiasis. According to WHO, by 1995, 20% of the world's population
suffered from mycoses of various localizations, and by the beginning of the 21st century, this
figure had doubled. This gives grounds to consider the spread of fungal infections as widespread.
In recent years, the opinion has become popular among mycologists that disorders of cellular
immunity, including those observed in HIV infection and AIDS, predispose almost exclusively
to superficial forms of candidiasis, and lesions of internal organs are impossible without a severe
disorder of phagocytosis. Analysis of clinical observations gives the right to consider this
opinion justified.
It has been proven that the severity of the specific tuberculosis process is more pronounced in
animals infected with fungi. A very significant difference in the severity of pathological changes
was found in the lungs: cavities were found in experimental tuberculosis infection in 8.9% of
cases, and in the presence of fungi - much more often (40%).
These experiments convincingly demonstrated the role of Candida fungi , which aggravate the
specific tuberculosis process. Similar observations were also obtained in patients with
tuberculosis.
Even if the doctor has modern antifungal agents in his arsenal that are highly active against
Candida spp ., treatment of visceral forms of candidiasis against the background of severe
immunodeficiency and neutropenia is rarely successful, and the patient, as a rule, dies.
Literature :
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Bartlett JG, Gallant JE. Medical management of HIV infection. Baltimore, MD, Johns
Hopkins University School of Medicine, 2000-2001.
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French N, Nakiyingi J, Carpenter LM, et al. 23-valent pneumococcal polysaccharide
vaccine in HIV-1 infected Ugandan adults: double-blind, randomized and placebo controlled trial.
Lancet, 2000, 355: 2106–2111.
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World Health Organization. Improving child health. IMCI: the integrated approach.
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9.
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children. Geneva, 1993.
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World Health Organization. AIDS in Africa: a manual for physicians. Geneva, 1992.
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