Chapter 5 Clinico-Immunologichesky indicators of a HIV-infection, sochetannoj with a tuberculosis against antiretrovirusnoj therapies
According to the Russian and international references, antiretrovirusnuju therapy (APT) prescribed the patient with a HIV-infection in the presence of the clinical implications testifying to an immunodeficiency and-or depression of number СЭ4-лимфоцитов more low 0,200-0,350 h 109/l.
In investigated group of 16 patients therapy has been prescribed antiretrovirusnaja. Two patients did not accept therapy (have refused). From 14 patients receiving therapy, 8 patients have independently interrupted therapy on terms from 5 months to the three patients receiving (APT) have died of tuberculosis advance. Three patients continue therapy on present time, from them 2 1 years sick more, 1 patient within 10 years.
Among the patients receiving therapy of 4 patients had an asymptomatic stage of a HIV-infection, antiretrovirusnaja therapy has been prescribed under laboratory indications; 10 patients had a stage of secondary diseases - therapy is prescribed under clinico-laboratory indications. And at 8 of them the tuberculosis has developed against a HIV-infection and was opportunistic disease. At 6 patients the tuberculosis was showed as accompanying disease.
In investigated group all patients, with activity of tubercular process, received 4-5 antituberculous preparations, the scheme of treatment of a tuberculosis at all included rifampicin. In this connection, in scheme APT did not include inhibitors of proteases. 11 patients received antiretrovirusnuju therapy under the scheme: 3 nukleozidnyh an inhibitor of return transkriptazy (kombivir on 1 tablet 150/300 h 2 times a day, ziagen on 1 tablet of 300 mg h 2 times a day), and 3 patients under the scheme: 2 nukleozidnyh an inhibitor of return
transkriptazy and 1 nenukleozidnyj an inhibitor of return transkriptazy (kombivir on 1 tablet 150/300 h 2 times a day, viramun on 1 tablet of 200 mg h 2 times a day).
In control group of 17 patients therapy is prescribed antiretrovirusnaja, 1 patient has refused therapy, 5 patients have independently interrupted therapy on terms from 4 months till 2 years. Two patients have died in connection with HIV-infection advance. 9 patients continue therapy on present time within 2-10 years. Among the patients receiving therapy in control group, 5 patients had an asymptomatic stage of a HIV - of an infection, antiretrovirusnaja therapy has been prescribed under laboratory indications. 11 patients had a stage of secondary implications, therapy is prescribed under clinico-laboratory indications. In control group 1 patient received antiretrovirusnuju therapy under the scheme: 3 nukleozidnyh an inhibitor of return transkriptazy; 10 patients under the scheme: 2 nukleozidnyh an inhibitor of return transkriptazy + 1 nenukleozidnyj an inhibitor
Return transkriptazy; and 5 patients under the scheme 2 nukleozidnyh an inhibitor of return transkriptazy + 1 inhibitor of a protease.
At sick HIV-infections, sochetannoj with a tuberculosis leading syndromes were weight loss (92,8 %), astheno-vegetative (85,7 %) and a bronho-pulmonary syndrome (78,6 %). At 78,6 % of patients the liver augmentation was observed. Against antiretrovirusnoj therapies have decreased implications of all syndromes, the infectious-toxic syndrome, dream disturbance, an arthralgia, an eruption and a skin itch, virus lesions of a skin (fig.
11, table 27) has disappeared. In 2,4 times it became perceptible astenovegetativnyj a syndrome less often, in 1,2 times is more rare bronholegochnyj, in 1,2 times weight loss is more rare. A bacteriemic lesion of a skin against therapy became perceptible less often in 3 times, and a mycotic affection in 1,5 times. Against therapy in 4 times the quantity of patients with an anorexia was enlarged.? Infectious-toxic ■ Astenovegetativnyj
And Bronholegochnyj
? Weight loss
104
Fig. 11. The basic clinical syndromes of a HIV-infection against antiretrovirusnoj therapies in investigated groups.
In comparison group leading syndromes before appointment antiretrovirusnoj therapies were liver augmentation (62,5 %), limfoadenopatija (56,3 %) and astenovegetativnyj a syndrome (56,3 %). In 2-2,3 times more often, than in investigated group met a lesion of a skin and mucous (a bacteriemic and fungoid aetiology) willows 1,5 times more often gastrointestinalnyj a syndrome. Against antiretrovirusnoj therapies the infectious-toxic syndrome, dream disturbance, a virus lesion of a skin has disappeared, in 3 times it became perceptible astenovegetativnyj a syndrome, in 2,3 times bacteriemic, and in 2,8 times fungoid skin lesions less often. Against spent antiviral therapy among by-effects were more often registered a lesion syndrome GASTROINTESTINAL TRACT, on 6,2 % the liver augmentation has been more often noted. In control group at 1 patient for 5 year of therapy the obliterating atherosclerosis of vessels of the bottom extremities (table 28), at 1 patient for 2 year of therapy - a toxic medicinal hepatitis with augmentation of activity ALT in 12 times, and normalisation of indicators after change of scheme APT has developed.
Table 27
Symptoms | Patients | |||
HIV-infection, sochetanyonoj with a tuberculosis (п=14) | HIV-infection (п=16) | |||
Before therapy | Against therapy | Before therapy | Against therapy | |
Temperature, fever | 42,8 | - | 6,3 | - |
Delicacy | 85,7 | 35,7 | 56,3 | 18,8 |
Headache | 14,3 | 7,1 | 18,8 | 6,3 |
Tussis, dyspnea | 78,6 | 64,2 | 25 | 6,3 |
Pains in a thorax | 14,3 | 14,3 | - | - |
Dream disturbance | 7,1 | - | 6,3 | - |
Arthralgia, mialgija | 7,1 | - | 6,3 | 6,3 |
Eruption and skin itch | 21,4 | - | 25 | 18,8 |
Bacteriemic lesion of a skin | 21,4 | 7,1 | 43,8 | 18,8 |
Virus lesion of a skin and mucous | 14,3 | - | 18,8 | - |
Mycotic affection of a skin and mucous | 21,4 | 14,3 | 50 | 18,8 |
Weight loss | 92,8 | 78,6 | 25 | 25 |
Limfoadenopatija | 50 | 50 | 56,3 | 50 |
Liver augmentation | 78,6 | 78,6 | 62,5 | 68,75 |
Chair disturbance | - | - | 6,3 | 18,8 |
Rigid breath | 64,2 | 50 | 12,5 | 6,3 |
Rhonchuses | 42,8 | 35,7 | 12,5 | 6,3 |
Pains in epigastriums | 21,4 | 21,4 | 31,3 | 43,8 |
Appetite loss | 7,1 | 28,5 | - | 6,3 |
Clinical implications of the patients receiving antiretrovirusnuju therapy in %
In investigated group, at patients receiving therapy, in a stage of secondary implications of a HIV-infection following opportunistic diseases are taped: Herpes zoster at 1 patient (7,1 %), a mycotic affection of a skin at 3 sick (21,4 %), an encephalopathy of the admixed genesis (a HIV + an alcoholism) - at 3 (21,4 %), a tuberculosis at 8 (57,1 %) patients. In control group, at the patients receiving therapy, opportunistic diseases are taped: widespread mycotic affections of a skin at 6 sick (37,5 %), an encephalopathy (a HIV caused) - at 3 patients
(18,8 %), Sarcoma Kaposhi - at 1 (6,3 %), Sa coli uteri - at 1 patient (6,3 %), a hairy leukoplakia of tongue - at 2 (12,5 %), peaked kandilemy - at 1 patient (6,3 %).
Secondary and accompanying diseases of the patients receiving antiretrovirusnuju therapy in %
Table 28
Symptoms | Sick HIV-infekYotsiej, sochetannoj with a tuberculosis (п=Т4) | Sick HIV - an infection (п=16) | ||
Before therapy | Against therapy | Before therapy | Against therapy | |
Cachexia | 42,8 | 42,8 | - | - |
Oral cavity candidiasis | 14,3 | 7,1 | 25 | - |
Mycoses | 21,4 | 14,3 | 37,5 | 6,3 |
Herpes zoster | 7,1 | - | - | - |
BUT | 14,3 | - | 18,8 | - |
Furunculosis | 21,4 | - | 37,5 | 6,3 |
Encephalopathy (according to KT) | 21,4 | 21,4 | 18,8 | 18,8 |
Anaemia | 14,3 | - | - | - |
Psoriasis | 7,1 | 7,1 | 12,5 | 12,5 |
Sarcoma Kaposhi | - | - | 6,3 | 6,3 |
Sa coli uteri | - | - | 6,3 | 6,3 |
Hairy leukoplakia Tongue | - | - | 12,5 | 12,5 |
Peaked kandilemy | - | - | 6,3 | 6,3 |
polinejropatija | 14,3 | 14,3 | - | 6,3 |
Depression | - | - | - | 18,8 |
Atherosclerosis of vessels | - | - | - | 6,3 |
Peptic ulcer | - | - | 6,3 | 6,3 |
Chronic bronchitis, pneumonia | - | 43,8 | 18,8 | |
Adenoid disease | - | - | 18,8 | - |
Toxic hepatitis | 57,1 | 71,4 | - | 6,3 |
Alcoholism | 57,1 | 57,1 | 12,5 | 12,5 |
TB - the opportunist | 57,1 | 57,1 | - | - |
TB - accompanying disease | 42,9 | 42,9 | - | - |
Chronic virus hepatitises | 87,5 | 87,5 | 56,25 | 56,25 |
At research of biochemical indicators of blood it is taped activity of enzymes of cytolysis of a liver in 1,3 time, a thymol turbidity test in 1,2 time and an alkaline phosphatase in 1,2 times against antiretrovirusnoj therapies that has been bound to by-effects of preparations and toxic action on a liver (table 29). In investigated group of 57,1 % of patients 85,7 % the chronic virus hepatitises suffered an alcoholism, and, all patients in connection with activity of tubercular process received 4-5 antituberculous preparations. In group of comparison of 12,5 % of patients suffered an alcoholism and 56,25 %-хроническими virus hepatitises. In connection with low level СО4-лимфоцитов in investigated group of 6 persons received chemoprophylaxis pnevmotsistnoj a pneumonia Biseptolum (960 mg h 3 times a week), and in control group 3 persons. In connection with a mycotic affection of a skin and mucous in investigated group 2 persons received difljukan, in control group 4 persons.
Table 29
Biochemical indicators of blood serum of the patients receiving antiretrovirusnuju therapy