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treatment sick of a tuberculosis, sochetannym with a HIV-infection in the conditions of children's tubercular unit of scientific research institute FP

On the basis of children's unit of a university hospital of scientific research institute ftiziopulmonologii the First MGMU of I.M.Sechenova, since 2007 on 2013гг., there have passed inspection and treatment of 36 children sick tuberkuyolezom, sochetannym with a HIV-infection (table 8.6).

Mainly on hospitalisation children living in Moscow and Moscow obyolasti arrived, but were and from other regions of the Russian Federation: from Republic Chuvashiya, Dagestan, Sverdlovsk, Ryazan, Ivanovo, Tver, Rosyotovsky areas.

Table 8.6 Quantity of the patients who were in scientific research institute FP on treatment on years

Years 2007 2008 2009 2010 2011 2012 2013 In total
Patients 1

(2,7)

- 3

(8,3)

8 (22,2) 6

(16,6)

6 (16,6) 12 (33,3) 36 (100)

Till 2010 it there were single instances. From 36 sick of a tuberculosis and HIV - an infection of 7 children arrived repeatedly for an exception of an exacerbation of tubercular process and carrying out protivoretsidivnogo treatments.

For the first time taped sick of a tuberculosis, sochetannym from a HIV - an infection, it is treated in children's unit of scientific research institute FP of 29 persons. From them boys and girls was approximately fifty-fifty-14 and 15 accordingly. SredYOny the age of children who were on treatment in unit, has made 6,84,2 years (from 4 till 13 years).

In structure of clinical forms of a tuberculosis (table 8.7) tuberculosis VGLU (34,5 %), a share of patients with PTK prevailed has made 20,7 %. At 10 children

(34,5 %) tubercular process is taped in an involution phase, in 3 cases - with bent to a chronic current. At two children tuberculosis VGLU proceeded with presence of complications (bronholegochnoe a lesion and eksyosudativnyj a pleuritis).

Table 8.7

Clinical forms TB at children who were on treatment in scientific research institute FP

Clinical forms TB Patients (n=29)
abs. %
TVGLU 10 34,5
PTK 6 20,7
Disseminirovannyj 3 10,3
The generalised 5 17,3
Mikobakterioz 3 10,3
TB peripheric LU 2 6,9
In total 29 100

Third of patients arrived on hospitalisation in a grave condition with widespread processes: the share of children with disseminirovannym and generayolizovannym a tuberculosis has made 27,6 %, besides among children with ustayonovlennoj mikobakterialnoj an infection at one child mikobakterioz had generalised character with a lesion of a pulmonary tissue and limfatiyocheskih knots intrathoracic, mezenterialnyh; at another - the child of 9 years diyoagnostirovana an infection caused by complex Mycobacterium avium against a serious immunodeficiency (CD4-0 cells/mkl)

At 5 of 10 patients with disseminirovannym and generalised protsesyosom (including mikobakterioz) its current was accompanied by a polyserositis in the form of an ascites, a pericarditis, a pleuritis.

MBT have been found out in 4 patients: at 2 - in a sputum, at one - in an exsudate and at one - in urine. Medicinal fastness MBT is taped at 3 children: in 2 cases - MLU and in one - usyotojchivost to Kanamycinum. At one patient in a sputum repeatedly obna -

265 ruzheny not tubercular micobacteria (NTMB) with wide medicinal fastness (SHLU) to antituberculous preparations.

In 3 cases in structure of clinical forms the lesion peyorifericheskih lymph nodes (a tuberculosis 2 is taped and mikobakterioz - at one child), processes are verified mikrobiologicheski at issleyodovanii a punctate.

At entering in clinic of scientific research institute FP at 23 sick (79,3 %) were ustayonovleny late stages of a HIV-infection (4Б, 4В), at six sick (20,7 %) - a subclinical stage (3).

In 70 % sluchaevv the anamnesis at children clinical implications of a HIV-infection are noted. At the moment of a finding of patients in clinic clinical implications of a HIV-infection became perceptible at 17 (58,6 %) children, the structure kotoyoryh is presented in table 8.8.

Clinical implications of a HIV-infection influenced not only gravity of a condition as at one patient some syndromes became perceptible, but also caused restrictions of appointment of antituberculous preparations.

So, restriction for rifampicin appointment (rifabutina) be a chronic hepatitis In, With (6,9 %), changes from a haemogram in viyode anemias, leukopenias and thrombocytopenias (44,8 %). Changes from eyes limited Ethambutolum appointment (6,9 %). Thus, half sick of a tuberculosis and a HIV-infection, required an individualization of chemotherapy under condition of its sufficient efficiency and safety.

Table 8.8 Clinical implications of a HIV-infection at the moment of treatment of patients

Clinical implications of a HIV-infection Patients
abs. %
G erpes surrounding herpesZoster 3 10,3
Molluscum contagious 2 6,9

Epstein Barr's virus (EB V) 6 20,7
Limfoma nehodzhkinskaja 1 3,4
Toxoplasmosis cerebral (maniyofestnyj) 1 3,4
Candidiasis of the mucous 3 10,3
Visceral candidiasis 1 3,4
Seborrheal dermatitis 4 13,8
Microsporia of a pilar part goloyovy 1 3,4
Chronic hepatitis In, With 2 6,9
Oligotrophy (including a cachexia) 6 20,7
G epatosplenomegalija 11 38,0
Leukopenia 4 13,8
Anaemia/thrombocytopenia 5/4 31,0
Horeoretinit, a serious astigmatism 2 6,9

Chemotherapy prescribed taking into account the clinical form of a tuberculosis, gravity of process and a condition, medicinal sensitivity MBT to PTP at separate patients, regimen VAART and an accompanying pathology.

VAART at the moment of entering in scientific research institute FP clinic received 75,9 % (22 of 29 patients).

With limited protsessamibez bakteriovydelenija at otyosutstvii high risk MLU MBT ilido receptions of results issledoyovanija medicinal sensitivity of the originator prescribed the patient 4 PTP pervoyogo a number with rifampicin including (in the absence of VAART or art without inyogibitorov proteases (IP). The intensive care phase made 3-4 months and a phase of continuation of 6-9 months usually 3 PTP (HZE) at udovletvoritel -

267 ache acceptabilities. The general course of chemotherapy made 9-12 months in zayovisimosti from a process current.

At disseminirovannom a pulmonary tuberculosis without involving in process of other organs and systems prescribed preparations of 1 number, but against VAART riyofampitsin replaced with two reserve preparations - Amikacinum, protiona - mid/ftorhinolon. A part of patients instead of rifampicin received rifabutin at its satisfactory shipping which was prescribed by 2-3 times a week. The patient with registered MLU MBT or established konyotaktom MLU MBT at an infection source prescribed the fourth regimen hiyomioterapii by the standard rules (table 8.9).

At generalised processes prescribed preparations of 1 number and 2 (reyozervnye) a number - amikatsin/kanamitsin, kapreomitsin, ftorhinolony, etc. (the chemotherapy regimen was individual depending on a condition of the patient, presence of pathological syndromes and symptoms of a HIV-infection, shipping of treatment, including antiretrovirusnogo etc.).

Table 8.9

Regimens HT at children sick of a tuberculosis, sochetannym from a HIV - an infection

Regimen HT

Patients

1 regimen 4 regimen "And" a regimen In total
HR (Rb) ZE/Am H*ZKm/Am/Cm [E] Lfx PAS Pto HZEKm/AmLfx/

PAS/Pto/Lzd

n=29 abs. 8 5 16 29
% 27,6 17,2 55,2 100

At appointment of Isoniazidum a preparation dose enlarged to 15-20 mg/kg of mass of a body.

At mikobakterioze (in one case have been allocated NTMB with ustojchiyovostju to R, S, To, Sar, Eto, PAS, Ofl) in the treatment scheme included preparations of a wide spectrum of action with antimikobakterialnoj activity - linezo - a lead (Lzd), klaritromitsin (Clr). An intensive care phase 12-24 months with the account klinicheyoskoj and radiological dynamics of process, restoration of the immune spent not meyonee 4-6 months and the general course of chemotherapy

Systems. Besides, the individual regimen of chemotherapy was received by children at whom collateral reactions on rifabutin (rifampicin not nayoznachali became perceptible, considering regimen art), and Pyrazinamidum, there were contraindications for treatment by Ethambutolum.

The collateral (undesirable) reactions registered at children at leyochenii by antituberculous preparations against art, are presented in table 8.10.

Adverse collateral reactions were observed in half of cases (58,6 %). Undesirable reactions in the form of a leukopenia (less than 3000 in 1 мм3 kroyovi) and thrombocytopenias (less than 100 thousand in 1 мм3 bloods) appeared at including in a chemotherapy regimen rifabutina at the initial maintenance of leucocytes 4,5-4тыс. In 1 мм3 bloods.

Table 8.10

Collateral reactions on PTP

Collateral reactions Patients
Abs. %
Rising of enzymes of a liver (ALT, nuclear heating plant) 4 13,8
Nausea, vomiting 2 6,9
Allergic eruption 3 10,3
Lejkopenija/a thrombocytopenia 8 (5/3) 27,6
In total 17 58,6

At cancellation of a preparation number of leucocytes in peripheric blood poyovyshalos. Rising of enzymes of a liver more than in 3 times was observed at Pyrazinamidum and rifampicin combination (rifabutina), chemotherapy correction, more often with rifampicin cancellation (rifayobutina) was as a result spent. Allergic reactions in the form of dermal eruptions observed seldom (10,3 %).

Simultaneously sick it was prescribed pathogenetic and simptomatiyocheskoe treatment. At immunosupressii with the replaceable purpose prescribed immunoglobulins (oktagam, an immunoglobulin of the person normal, other).

At the expressed exudative reactions (polyserosites) prescribed kortiyokosteroidnye preparations (metiprednizolon) in small doses (0,5-1мг on kgmassy bodies). In coordination with the doctor infektsionistom spent lecheyonie secondary infections.

For the purpose of the prevention lekarstvenno the induced lesion of a liver (LIPP) to all patients receiving antituberculous terayopiju, prescribed a preparation ursodeoksiholevoj acids (UDHK) - ursosan, javyoljajushchijsja gepatoprotektornym a preparation (the patent for the invention № 2473346 the Way of treatment of the lekarstvenno-induced lesion peyocheni at children sick of a pulmonary tuberculosis is received).

As follows from references, at treatment of a HIV - of the infected patients with a tuberculosis, approximately in 30 cases voznikayoet paradoksalnoeuhudshenie, bound to function restoration immunyonoj systems at the beginning antiretrovirusnoj to therapy (VSVI - vospalitelyonyj a syndrome of restoration of immunity or SVIS - a syndrome vosstanovleyonija immune system). SVIS usually arises within six weeks after the beginning antiretrovirusnoj therapies at patients with low initial quantity of cells CD4 (less 50kl/mkl).

In our research at the patients who have arrived on treatment in scientific research institute FP, it is possible to say about SVIS in one case from 10 for the first time taped tuberkuyoleznyh processes with prescribed art the day before, that has made 10 %. So rezyokoe the aggravation of symptoms was observed at the girl of 13 years with for the first time diagnoyostirovannoj a HIV-infektsiejna a background of deeply immunodeficiency (CD4 sostavyoljali 20 kl/mkl) at appointment art and simultaneous joining PTP generalisation of a tubercular infection became perceptible. A condition stabiliziroyovalos against reception of corticosteroid hormones (Methypredum) in a usual therapeutic dose (0,5-1 mg on kg of mass of a body) without cancellation art.

8.4.

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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

Other medical related information treatment sick of a tuberculosis, sochetannym with a HIV-infection in the conditions of children's tubercular unit of scientific research institute FP:

  1. THE TABLE OF CONTENTS
  2. INTRODUCTION
  3. clinical aspects of a tuberculosis, sochetannogo with a HIV-infection
  4. diagnostics of a tuberculosis at children with a HIV-infection
  5. treatment of children sick of a tuberculosis, sochetannym from a HIV - an infection
  6. tuberculosis diffusion, sochetannogo with a HIV-infection, among children of 0-14 years
  7. testing of children of 0-14 years sick of a tuberculosis for a HIV-infection
  8. 4.1.1. Clinical implications of a tuberculosis at children with a HIV-infection
  9. structure of clinical forms of a tuberculosis at children with a HIV-infection
  10. complications of tubercular process at children with a HIV-infection
  11. 4.2.1. Methods of revealing of a tuberculosis at children with a HIV-infection