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Causes of Death in HIV-infected Adults with TB Admitted to 2 Hospitals in Soweto, South Africa
Neil Martinson*1,2, Neil Martinson*1,2, M Hale2,3, M Hale2,3, A Karstaedt2,4, A Karstaedt2,4, F Venter2, P King2,3, P King2,3, E Marais2,3, E Marais2,3, and R Chaisson1
1Johns Hopkins Univ Ctr for TB Res, Baltimore, MD, US; 2Univ of the Witwatersrand, Johannesburg, South Africa; 3Natl Hlth Lab Svc, Johannesburg, South Africa; and 4Chris Hani Baragwanath Hosp, Soweto, South Africa
Background: A quarter of adults treated for active TB in
high HIV-prevalence settings will die while on treatment, most in the initial
days or weeks after diagnosis. TB is the leading cause of death in HIV-infected
adults. With improving access to life-sparing ART, it is increasingly important
to address the high mortality in co-infected TB patients, but little is known
about its causes. We ascertained immediate and underlying causes of death in 47
HIV+ adults who had died in hospital with an ante-mortem diagnosis
of TB.
Methods: Complete autopsies—including an HIV test,
microscopic assessment of all organs with special stains for fungae, cytomegalovirus, and pneumocystis
in lung specimens and post-mortem cultures of splenic
and lung tissue—were performed on 50 adults admitted to 2 hospitals serving
Soweto. Causes of death were categorized as immediate or contributory and coded
using the International Classification of Diseases-10 (ICD-10).
Results: Of the 47 infected with HIV, 26 were women and
21 were men. Their median age was 34.5 years. CD4 count, length of hospital
stay, and duration on TB therapy was 48 cells, 6 days, and 2.4 weeks, respectively.
Pulmonary TB was the immediate cause of death in 19 and bacterial pneumonia in 4.
Disseminated TB was the immediate cause of death in 4 and a contributory cause
of death in another 28. Cytomegalovirus pneumonitis
was the immediate or contributing cause of death in 7 and Pneumocystis carinii pneumonia in 3. Multiple
pathologies were found in all but 2. Lung, lymph node, and liver were the most
frequent sites of TB; 8 had adrenal and 4 intracranial TB. Salmonella was isolated from 11 post-mortem lung or splenic specimens and Mycobacterium
tuberculosis from 23 splenic samples, one of
which was multi-drug resistant.
Conclusions: Extensive pulmonary TB with dissemination and
multiple HIV-associated pathologies were found, signifying that earlier
diagnosis of both HIV and TB is urgently needed. Severe bacterial infections
were the leading co-morbidity suggesting that hospitalized, HIV-infected adults
with TB may benefit from potent, broad-spectrum antibiotics.
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