clinical aspects of a tuberculosis, sochetannogo with a HIV-infection

Mechanisms of transition of a latent tubercular infection in active tuyoberkulez are not clear till now. Micobacteria of a tuberculosis can decades osyotavatsja isolated in cells and granulomas, not causing disease, odyonako can show activity again at depression of level cellular immuyoniteta (for example as a result of a HIV-infection, treatment by glucocorticoids etc.) [94].

At a HIV-infection in process of depression of number of lymphocytes CD4 in rezulyotate HIV influences secretion of lymphokines by lymphocytes CD4 decreases, neyoobhodimyh for activation of macrophages, the probability of times - as a result raises

25 vitija active forms of a tuberculosis [224,293]. Though the risk of development of a tuberculosis moyozhet to be raised and at normal maintenance CD4 of lymphocytes because synthesis by lymphocytes of interferon at, playing the major role in immuniyotete against micobacteria, considerably decreases at a HIV-infection [274].

Thus, it is possible to assume, that the HIV-infection strengthens predyoraspolozhennost to disease by a tuberculosis, in view of depression T-helpernogo otyoveta type 1, thereby lowering ability of an organism effectively to constrain development of an infection [227,228,236].

On the other hand the great value has influence MBT on a HIV-infection current. In some researches it has been shown, that at a tuberculosis activation of the immune answer strengthens a HIV reproduction that leads to reduction of number of lymphocytes CD4 iprogressirovaniju a HIV-infection the risk of development of opportunistic infections and vozmozhyonogo a lethal outcome [163, 164, 165], as consequence, raises. In an acute phase of a tuberculosis (without treatment) level RNK the HIV in a blood plasma can raise in 5-160 times [210].

Thus, the tubercular infection and a HIV-infection - vzaimovlijaju - shchie against each other diseases and a tuberculosis current, its clinical picture at children with a HIV-infection, will depend on a current of the HIV-infection.

As a whole clinical implications of a tubercular infection can razliyochatsja depending on age of the patient and a condition of immune system. Without preventive treatment tuberculosis symptoms appear within 1-2 years after infection at 40-50 % of children of early age with a HIV-infection and at 15 % deyotej more advanced age. At children of the first months of a life the period between zarayozheniem and occurrence of symptoms of a tuberculosis can be very short and soyostavljat 6-8 weeks [126].

The published data in foreign sources about sick HIV - an infection children with a tuberculosis, are presented basically by descriptions edinichyonyh or not numerous cases [186,198,199,269,290,303,304]. Authors otmeyochajut, that as a whole clinical lines of a tuberculosis at children with a HIV-infection and at children without a HIV-infection are similar. However at the first disease proceeds more

Acutely, clinical implications, including a fever and kayoshel are more often observed. The risk miliarnogo a tuberculosis and a tubercular meningitis is raised at a HIV-infected of children, as well as at children of younger age in general populjayotsii. Besides authors do the assumption, that at children with a HIV-infection frequency vnelegochnogo a tuberculosis should be above, than at children without an infection HIV - (vnelegochnyj the tuberculosis is diagnosed approximately for 25 % of children with tuyoberkulezom in the general population).

Last years the problem of medicinal fastness of micobacteria and vyyozyvaemogo them of a tuberculosis became actual and at children. The tuberculosis at children with leyokarstvennoj fastness (LU) MBT is usually result of transfer usyotojchivogo the strain from a source with which the child was in contact. Though in some cases medicinal fastness MBT can be got [198, 199, 269, 290]. Whether higher risk of development LU MBT is bound to a HIV - an infection? - Data are inconsistent.

On some researches most often arises lekarstvenno - usyotojchivyj a tuberculosis at children with a HIV-infection, passing treatment concerning a tuberculosis, mainly in industrially developed countries. RasprostranenYOnost a tuberculosis with fastness MBT to Isoniazidum made 7-13 %, and with MLU MBT - 4-10 %, from them about 48 % of children were with a HIV-infection [189, 288]. On mneyoniju separate authors, against a HIV-infection a tuberculosis with LU MBT more often priyovodit to mors of patients, than tuberkulezs sensitive strains MBT [238]. On researches of other authors, significant communication not bylovyjavleno between a leyokarstvenno-steady tuberculosis and a HIV-infection at children [198, 199, 269, 290].

Experts the CART allocate the basic clinical symptoms of disease by a tuberculosis at children: long tussis (without visible improvement within 21 days), the raised body temperature (above 38°С within 14 days at isyokljuchenii other diseases), depression of mass of a body or retardation of its growth [126].

Numerous enough researches are spent to Russia on a current and clinical implications of a tuberculosis, sochetannogo with a HIV-infection, among adults. As authors of researches note, the clinical picture and a tuberculosis current depend on a stage of a HIV-infection, degree of oppression immune sisyotemy. At absence immunosupressii structure of clinical forms and klinicheyoskie tuberculosis implications do not differ from those at sick of a tuberculosis without a HIV-infection. Infiltrativnyj a tuberculosis preobladaetv 36,5-42,9 % sluyochaev, the focal tuberculosis is registered in 11,8-14,3 % of cases, miliarnyj tuyoberkulez - in 4,3-8,6 % of cases, vnelegochnyj a tuberculosis - in 11,4 % and other forms of a tuberculosis in 4-8,6 % of cases [46, 60, 62, 93, 95,129, 133]. At depression of number of lymphocytes CD4 less than 500 cages/mkl the tuberculosis proceeds more acutely, frequency of a destruction of a pulmonary tissue with share reduction bakteriovyyodelitelej decreases, intrathoracic lymph nodes, serous covers are involved in process. At further depression CD4 of cells a tubercular inflammation stayonovitsja the atypical: start to prevail disseminirovannye processes, peryovichnye processes with a lesion of intrathoracic lymph nodes (VGLU), involving in pleura and pericardium process [46, 51, 52, 60, 93].

Tuberculosis diagnostics in such situation is complicated, as rentgeyonologicheski processes of morphological implications in leyogochnoj tissues (dissimination) are not always displayed, besides at a deep immunodeficiency tuberkuyolez is accompanied by presence of other secondary diseases which can dayovat similar clinic [14, 15, 23, 62].

Clinical forms of a tuberculosis at children basically differ from takoyovyh at adults. For children about 12-14 years are elderly forms of a primary tuberculosis with a primary lesion of intrathoracic lymph nodes (VGLU) are characteristic. A tuberculosis share vnutritrigrudnyh lymph nodes sostavyoljaet in structure of a case rate of 72-78 % [118, 119], the "small" forms proceeding clinically asymptomatically, by which method of revealing javyoljaetsja a tuberculinodiagnosis with the subsequent manufacture of a computer tomography (KT) [32,33,37,57] are more often taped. At children about 7 years tuberculosis VGLU are elderly about -

28 tekaet with a lesion of a pulmonary tissue in 9,2 %, at children of 7-14 years - in 29,1 % of cases (at teenagers secondary forms of a tuberculosis with a lesion of a parenchyma of lungs - in 86,5 % of cases prevail) [6]. The share of patients with primary tubercular komyopleksom makes only 2,5-10 %. [88].

The widespread and complicated processes of a primary tuberculosis in larger degree are characteristic for children of early age, the diseased in the centres tuyoberkuleznoj infections [74, 150]. Despite a small share of children with bakterioyovydeleniem (5-6 %), among for the first time diseased at the age of 0-14 years allocating micobacteria with MLU to antituberculous preparations (PTP), among them dosyotatochno it is high and tends to augmentation: from 22,5 % of cases in 2010г. To 27,9 % - in 2013 [3].

Domestic publications on clinical implications of a tuberculosis at deyotej with a HIV-infection individual, basically observations on limited koyolichestve patients [21,22,47,108,123,154].

As authors, risk factors of development of a tuberculosis at children, rozhyodennyh from sick HIV-infections of women note, were contact to patients tuyoberkulezom adults (more often family) - from 63,3 % to 83 % of cases, absence of bacterination BTSZH and preventive treatment concerning contact at bolshinstyova children (about 50 %). N.V.Ejsmonti of co-workers. [154] on a cohort of children born from sick HIV-infections of mothers, have shown, that a case rate a tuberculosis of children with a HIV-infection at the age of 0-14 years in 55,2-193,5 above, than at children without a HIV-infection. Most often the tuberculosis was registered in age group 1-3 years and 7-14 years, at late stages of a HIV-infection, av to structure of clinical forms diagnosed tuberculosis VGLU (63,3 %) and primary tuberkulezyonyj a complex (26,5 %) is more often. Miliarnyj a tuberculosis of plural localisation (geneyoralizovannyj) registered at children of the early age who has been not vaccinated BTSZH, from contact to a sick tuberculosis.

Thus, available data on a current of a tuberculosis at children, bolyonyh a HIV-infection, are rather limited. And the tuberculosis problem, sochetannogo with a HIV-infection at children, demands the further studying.


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Scientific source KLEVNO HOPE IVANOVNA. TUBERCULOSIS At CHILDREN, SICK HIV-INFECTIONS (prevalence, features of clinical implications, diagnostics, treatment, preventive maintenance). The dissertation on competition of a scientific degree of the doctor of medical sciences. Moscow - 2015. 2015

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