3. Clinical presentation

TB disease can be diagnosed at any stage of HIV infection and is very often the first recognized manifestation of the underlying HIV infection. Clinical manifestations of TB in HIV seropositive patients depend on the degree of immune suppression.

In the initial stage, at higher CD4 count, the patient may present with a typical apical cavitary lung lesion, and is likely smear-positive. At more advanced immune suppression the majority of the patients will present with smear-negative and/or extra-pulmonary TB, which is more difficult to diagnose.

Pulmonary TB (PTB): In some patients clinical features are classical (cough, hemoptysis, fever, night sweats, weight loss, general weakness, shortness of breath). Other may present with few of those symptoms or may have less specific presentations or even be asymptomatic.

Findings on chest X–ray (CXR) might reveal typical upper lobe infiltrates with or without cavities, but with advanced immunosuppression lower lobes infiltrates, mediastinal lymphadenopathy and miliary TB are more common. Some patients might present with normal CXR (up to 20% of patients).

Patients with HIV-TB co-infection are less likely to develop cavitary disease (especially in severe immunosuppression) and lower prevalence of cavitary disease is consistent with less prevalent sputum smear positive PTB in HIV co-infected.

Extra-pulmonary TB (EPTB): The risk of EPTB is higher in patients with lower CD4. The most common forms of EPTB are lymphatic and pleural, but almost any organ/tissue can be involved: bones, joints, soft tissues, CNS, eye, skin, pericardium, kidney, liver, etc.

Symptoms are usually typical for the site(lymphadenopathy, chest pain, dyspnea, back pain, spine deformities, headache, meningismus, abscesses, abdominal pain, hematopyuria, etc) and may or may not accompanied with systemic manifestations(fever, night sweats, loss of appetite, loss of weight, general weakness, anemia). Very often symptoms and signs overlap with clinical presentation of other opportunistic infections. Some patients might develop disseminated miliary TB.

Figure 2: Type of TB in function of CD4 count
(Source: slide by L. Lynen)