RADIOGRAPHIC PRESENTATION OF PULMONARY TUBERCULOSIS IN SEVERELY IMMUNOSUPPRESSED HIV-SEROPOSITIVE PATIENTS

Although the presence of typical postprimary or ''reactivation'' patte rn tuberculosis (TB) on chest radiograph (CXR) strongly suggests Tn in fection in adults, the sensitivity of this finding, particularly in se verely immunosuppressed human immunodeficiency virus (HIV) patients, i s unclear. To investigate this issue, HIV status, CD4 counts, and CXR findings of all adult patients with culture proven TB admitted to a te rtiary-care hospital over a 2-year period were retrospectively studied . CXRs were classified as typical for postprimary Tn if they showed up per lobe opacities with or without cavitation. No attempt was made to correlate the actual clinical phase of Tn infection (primary versus po stprimary) with CXR patterns, largely because differentiating primary from postprimary TB in HIV patients is difficult due to high anergy ra tes and inability to skin-test-convert. Of 46 patients who had chest r adiographs and medical records documenting HIV status available for re view, 23 were HIV seropositive and 23 were HIV-seronegative. Of 22 HIV -seropositive patients whose CD4 counts were available, 18 (82%) had C D4 counts of <200 cells/mu l. Only 2 of these 18 (11%) had CXRs showin g a typical postprimary TB pattern, whereas all 4 (100%) patients with CD4 counts of >200 cells/mu l and 18 of 23 (78%) non HIV patients had CXRs typical for postprimary TB (P<.005). It was concluded that HIV-s eropositive patients with TB and CD4 counts of <200 cells/mu L frequen tly present with chest radiographs atypical for postprimary TB, includ ing normal CXRs. Typical postprimary TB CXR findings are not sensitive for diagnosing pulmonary Tn in this population. Copyright (C) 1996 by W.B. Saunders Company.