The Corelation Between CD4+ T-lymphocyte Count … · The Corelation Between CD4+ T-lymphocyte Count and Tuberculosis Form in TB-HIV Coinfected Patients in Indonesia ... menjadi TB

122

ORIGINAL ARTICLE

Acta Medica Indonesiana - The Indonesian Journal of Internal Medicine

The Corelation Between CD4+ T-lymphocyte Count and Tuberculosis Form in TB-HIV Coinfected Patients in Indonesia

Felix C. Fredy, Frans Liwang, Rudy Kurniawan, Anna Uyainah Z. NasirDepartment of Internal Medicine, Faculty of Medicine, University of Indonesia – Cipto Mangunkusumo Hospital. Jl. Diponegoro no. 71, Jakarta Pusat, 10430, Indonesia. Correspondence mail: [email protected].

ABSTRAKTujuan: untuk mengetahui apakah terdapat korelasi antara jumlah CD4+ dengan jenis TB pada pasien

TB-HIV di Indonesia. Metode: penelitian ini merupakan studi potong lintang dari pasien TB-HIV yang terdaftar di POKDISUS, Rumah Sakit Cipto Mangunkusumo pada tahun 2008-2011. Peneliti membedakan jenis TB menjadi TB paru, TB ekstraparu, dan TB miliar, dan jenis campuran. Data kemudian dianalisis dengan tes korelasi Spearman dan Lambda. Peneliti juga melakukan uji korelasi parsial untuk mengeliminasi beberapa faktor perancu, termasuk faktor demografi (umur, jenis kelamin, dan IMT) dan karakteristik klinis (derajat klinis HIV, pulasan bakteri tahan asam, dan laju endap darah). Hasil: sebanyak 122 pasien TB-HIV (median umur 31 [18-34], 80% laki-laki) tergabung dalam penelitian ini. Prevalensi jenis TB yang didapat adalah TB paru (71%), TB esktraparu (7,4%), TB kombinasi (18,9%), dan TB milier (2,5%). Median jumlah CD4 adalah 40 sel/ml (RIK 17,5-100,6). Berdasarkan hasil analisis statistik, terdapat korelasi sangat lemah antara jumlah CD4+ dengan jenis TB pada pasien TB-HIV di Indonesia (r=0,185, p=0,042). Faktor lain yang memiliki korelasi adalah derajat klinis HIV (r=0,289; p=0,001). Setelah dilakukan penyesuaian terhadap berbagai faktor tersebut, peneliti menemukan bahwa terdapat peningkatan korelasi antara jumlah CD4+ dengan jenis TB di Indonesia (r=0,353; p=0,000). Kesimpulan: terdapat korelasi antara jumlah CD4+ dan jenis TB pada pasien TB-HIV di Indonesia, tetapi merupakan korelasi yang sangat lemah.

Kata kunci: koinfeksi TB-HIV, jumlah CD4+, jenis TB.

ABSTRACTAim: to find whether there is a correlation between CD4+ count and TB form in TB-HIV Coinfected patients

in Indonesia. Methods: this is a cross-sectional study of the TB-HIV patients at National HIV Center POKDISUS, Cipto Mangunkusumo Hospital in 2008-2011. We classified TB form as pulmonary TB, extrapulmonary TB, milliary TB, and combination form. The data were analyzed by Spearman and lambda correlation test. We also did partial correlation test to eliminate some counfounding factors, including demography and clinical characteristics, that had been determinated before. Results: there were 122 TB-HIV patients (aged median 31 [18-34], 80% male) included in this study. The most common TB form was pulmonary TB (71.2%), then extrapulmonary TB (7.4%), the combined type (18.9%), and milliary TB (2.5%). Median of CD4+ count was 40 cells/mL (IQR 17.5-100.6). There was a very weak correlation between CD4+ count and TB form in TB-HIV patients in Indonesia (r=0.185; p=0.042). The other factor that also showed a significant correlation to TB form is HIV staging (r=0.289; p=0.001). After adjusting those factors, we found an increase on correlation between CD4+ count and TB form (r=0.353; p=0.000). Conclucion: there was a correlation between CD4+ count and TB form in TB-HIV patients in Indonesia, but in a very weak correlation.

Key words: TB-HIV coinfection, CD4+ count, TB form.

Vol 44 • Number 2 • April 2012 The Correlation Between CD4+ T-lymphocyte Count and Tb Form

123

INTRODUCTIONTuberculosis is the major leading opportunistic

infection and also the leading cause of death in HIV patients. TB coinfected patients usually have higher viral load, and more rapid decline in immune status.1,2 However, TB and HIV also have sinergic effects to human body. TB could induce the macrophage to produce some transcription factors (TNF α, IL-1, Il-6) with the increasing of HIV replication rates. On the other hand, HIV could lower the immune system like CD4+ T-Lymphocyte and as a consequence, the risk of TB opportunistic infection will also increase with lack of immune response.3

Due to the defect in immune response, it is difficult to identify TB manifestations in TB-HIV patients, especially in advanced stage HIV patients.3 The clinical manifestations of TB in HIV patients are often unclear, such as negative stainning sputum, atypical chest x-ray pattern, and quite similar to the other pulmonary opportunistic infections. Moreover, the prevalence of extrapulmonary TB form at the first diagnose is higher in TB-HIV patients.4 In Cipto Mangunkusumo General Hospital, Jakarta, 2009, the number of TB-HIV patients are 175 patients, with 161 patients (92.0%) diagnosed as pulmonary TB at the first visit and 14 patients (18.0%) diagnosed as extrapulmonary TB.5 This different form of TB is certainly very important to be identified by clinician because of their different treatment approach.

Based on the problem mentioned, the immunity status of HIV patients, such as CD4+ T-Lymphocyte count, is hypothesized as a TB form predictor in TB-HIV patients. Extrapulmonary or miliary TB are frequently encountered in advanced HIV patients (CD4+ <200). We conduct this study to find the correlation between CD4+ count and TB form in high TB prevalence country, such as Indonesia. We hypothesize that CD4+ count has a correlation with the TB form in Indonesia.

METHODSIt was a cross-sectional study, using

secondary data from National HIV Center named POKDISUS, Cipto Mangunkusumo Hospital, Indonesia in 2008-2011. All the data has received approval from the ethical committee for Medical Research in Faculty of Medicine, University

of Indonesia, and we also have been obtained permission to used the data from Pulmonology Division, Department of Internal Medicine, Cipto Mangunkusumo National Public Hospital.

Subjects included all TB-HIV coinfected outpatients. We collected any demographical and clinical data, such as age, sex, education level, body mass index (BMI), mode of transmission, acid fast bacilli (AFB), erythrocyte sedimentation rate (ESR), TB form, category of TB treatment, and CD4+ count. The subjects would be excluded from the analysis if any characteristics data were not complete.

The data were shown as mean, standard deviation (SD), median and or range. According to WHO classification for antiretroviral usage, CD4+ count are categorized into three groups: <200, 200-350, and >350 /mm3. The HIV staging based on WHO clinical presentation was divided into stage I, II, III, and IV. It is defined the TB form as pulmonary TB, extrapulmonary TB, combined pulmonary and extrapulmonary TB, and milliary TB. Only two types of staining, negative or positive were valid to be included into this study.

Data were analyzed by bivariate correlation lambda analysis and Spearman rank’s test for each nominal and categorical data respectively. Furthermore, partial correlation test was conducted to find out the correlation between CD4+ count and TB after adjusting other factors that might be influenced. All data were processed by SPSS 17.0.

RESULTS

The total 122 data of the TB-HIV coinfected patients within 3 years were included in analysis. Most subjects are male and in reproductive age. In this study, drugs used is the main transmission mode of HIV. None of the subjects are HIV stage I and II. More than half of them are HIV stage III while the remaining are stage IV. All TB form can be found among the subjects, but the most common is pulmonary TB, followed by combined pulmonary and extrapulmonary, extrapulmonary, and milliary TB. Median CD4+ count amount is extremely low (Table 1).

Bivariate analysis was performed to identify the correlation between CD4+ count and TB form. A very weak correlation exists between CD4+ count and TB form shows very low

Felix C. Fredy Acta Med Indones-Indones J Intern Med

124

correlation (r=0.185; p=0.042). This study also did correlation test for other clinical and demographic characteristics that might have correlation with TB form. Among them, sex, AFB, and HIV staging show a significant correlation where sex and AFB show a very weak

correlation while HIV staging shows a weak correlation. The others, including age, BMI, and ESR, does not show any significant correlations (Table 2).

The strength of correlation between CD4+ count and TB form increases when factors that have a significant correlation in bivariate analysis were adjusted (Table 3). However, it also was seen when other clinical and demographic factors were adjusted.

Table 1. Subject characteristics

Characteristics Subject (n=122)

Age (year) (median, IQR) 31 (28-34)

Sex (n, %)

- Male 101 (82.8)

- Female 21 (17.2)

Education (n, %)

- No education background 1 (0.8)

- Elementary school 5 (4.1)

- Junior high school 13 (10.7)

- Senior high school 80 (65.6)

- College 23 (18.8)

Body Mass Index (BMI)(Kg/m2) (n, %)

- Under weight 69 (56.6)

- Normal 42 (34.4)

- Over weight 5 (4.1)

- Obese 6 (4.9)

Mode of transmission (n, %)

- Sexual intercourse 31 (25.4)

- Drugs user 70 (57.4)

- Blood transmission 0 (0.0)

- Others 21 (17.2)

Acid Fast Staining (n, %)

- Positive 22 (18.0)

- Negative 100 (82.0)

ESR (mean ± SD) 77.3±32.5

HIV staging (n, %)

- Stage I 0 (0.0)

- Stage II 0 (0.0)

- Stage III 72 (59.0)

- Stage IV 50 (41.0)

TB form (n, %)

- Pulmonary TB 87 (71.2)

- Extrapulmonary TB 9 (7.4)

- Combined pulmonary and extrapulmonary

23 (18.9)

- Milliary 3 (2.5)

Category of TB treatment (n, %)

- Category 1 107 (87.7)

- Category 2 15 (12.3)

CD4+ Count (median, IQR) 40 (17.5- 100.6)

Table 2. Correlation between CD4+ count, age, sex, mode of transmission, HIV staging, AFB, ESR, and TB form (bivariate analysis)

r p

CD4+ Count1 0.185 0.042

Age1 –0.045 0.622

Sex2 0.000 0.000

BMI1 –0.021 0.817

HIV Staging1 0.289 0.001

AFB2 0.000 0.000

ESR1 0.064 0.481

1 Spearman’s Rank Correlation Test2 Contingency Coefficient Lambda Test

Table 3. Partial correlation between CD4+ and TB form

r pAdjusted for HIV staging 0.333 0,000

Adjusted for demographical characteristics (age, sex, BMI) 0.346 0,000

Adjusted for clinical characteristics (HIV staging, AFB, ESR) 0.338 0,000

Adjusted for age, sex, BMI, staging, AFB, ESR 0.369 0,000

DISCUSSION

Subject CharacteristicsAs one of the countries in the world with the

highest TB prevalence, Indonesia may show a different correlation between CD4+ count and TB form, compared to other countries. HIV/AIDS patients in Indonesia usually come to the hospital after in advanced stage; therefore, we found all subjects are in HIV stage III and IV with the median of CD4+ count is 40 cells/μL.6-8 On the other hand, our data show the similar characteristics to the national epidemiology data that the main modes of transmission are sexual intercourse and drug users. However, the quite

Vol 44 • Number 2 • April 2012 The Correlation Between CD4+ T-lymphocyte Count and Tb Form

125

interesting fact is most of the subjects come from well educated people instead of from low educated people.9,10

TB-HIV in the High TB Prevalence CountryIn this study, the correlation between CD4+

and TB forms is significant, but very weak. This finding is different from other previous studies in several countries due to the different prevalence of TB. In the countries with low prevalence of TB, most of the patients are elderly population due to reactivation of latent infection. However, that mechanism will be different in other countries with higher TB transmission or stable for many years, such as Indonesia. TB cases are more likely found in young adults population because of recent infection or reinfection.10-12 A study in Isparta showed that the severity forms of TB, such as extrapulmonary TB, increase steadily with age.11 It can be predicted that TB has greater chance to become more severe or extrapulmonary form in Indonesian.

It is clear that not all of the TB infection will manifest as TB illness. However, only 70% will become primary TB. In several conditions, this pathogenesis will lead to pulmonary TB, extrapulmonary TB, or latent TB infected (LTBI). The probabilities of those TB forms will be different in TB-HIV patients. At the time people infected by HIV in which the CD4+ count is high, TB can be already in any forms. When the HIV starts lowering immune system, the primary TB can be easily transformed to progressive primary TB and extrapulmonary TB. In the others who have already had extrapulmonary TB, it will still remain extrapulmonary TB or even become combined TB form. In these cases, CD4+ fails to predict the severity of TB.

Cellular Response in Coinfected TB-HIV Patients

For immunocompromised infected people, TB granuloma formation is unsuccessfully initiated in containing the bacilli. The necrotic tissue undergoes liquefaction, and the fibrous wall loses structural integrity. The semiliquid necrotic material can then drain into a bronchus or nearby blood vessel, leaving an air-filled cavity at the original site becoming extrapulmonary TB.13

Investigators have shown that M tuberculosis can also increase viral replication in infected T lymphocytes and monocytes in HIV patients. A recent study demonstrated a 5- to 160-fold

increase in viral replication during the acute phase of untreated tuberculosis. The clinical significance of this increase in viral load is uncertain. Moreover, high levels of tumor necrosis factor (TNF)-α, which is known to increase HIV replication and viremia, have been demonstrated in both HIV-seropositive and -seronegative tuberculosis cases.14 Besides, IFN-γ production is decreased in parallel with reduction in CD4+ cells, leading to increased risk of reactivation of or infection with tuberculosis.15

Based on these findings, HIV infected people will be more vulnerable to get TB infection. In addition, the TB infection is more progressive. As a result, TB-HIV infected people could have more severe TB although the CD4+ count, its immune system, is still high. It explains why in our study we did not find any correlation between CD4+ and TB form.

TB Form and Affecting FactorsIn order to figure out the confounding factors,

we did correlation analysis between demographic and clinical characteristics with TB form. Those characteristics include age, sex, BMI, staining, and ESR.

According to Rodwell et al, foreign-born TB–HIV coinfected individuals are reported to be in the United States for an average of 13,1 years before being diagnosed, which was not significantly different (p=0.346) from individuals in the TB–HIV negative group (14.0 years) and TB–HIV unknown group (18.0 years).16

Study conducted by Forssbohm shows that females were more likely than males to have extrapulmonary TB in all countries, and in virtually every age group. The reason is not clearly explained, but it suggests that endocrine factors might play a role.17,18

BMI could indirectly describe human imunity function which influence the progress of the disease. In many publication before, TB-HIV patients have BMI lower than TB or HIV significantly. Moreover, lower BMI could become strong predictor to HIV patients mortality.19,20

According to previous studies, there is no correlation between CD4+ count and the staging of HIV patients. It only shows that the decreasing of CD4+ count is followed by increasing the viral load. However, in TB-HIV Coinfected patients, this correlation was not clear. There is a dissociation between immunological and HIV

Felix C. Fredy Acta Med Indones-Indones J Intern Med

126

virological markers, even the staging of HIV patients.19,21-23

Smear-negative TB occurs more frequently in HIV-infected patients compared to the general population. However, Shea, et al already proved that acid-fast staining is still sensitive and specific for diagnosis TB in an African population with high prevalence of HIV. HIV positive is more likely found in acid fast staining with a large number of bacilli (+2 and +3).24,25

The role of erythrocyte sedimentation rate (ESR) in monitoring HIV/AIDS is still controversial.26 A study in South Africa shows that 76% ESR 100 and above are HIV-positive patients.27 Furthermore, a study conducted by Ndakotsu concluded TB-HIV patients and people with low CD4+ count had ESR higher than asymptomatic patients.28 Indeed a elevated ESR may have a relation with clinical and immune status in HIV infected patients.

After adjusting those factors, we did not find any significant improvements in CD4+ count and TB form correlation. We assume there are other factors that affect TB manifestation in HIV infected people.

Although this study can represent the typical HIV/AIDS patients in Indonesia, it still can not cover all patients because of limitation in case finding. Subjects are the patients from national referral hospital. Another limitation is the limited sample size included in analysis. It is much better if the onset of TB and HIV be known. The causative analysis can be done if these data are provided.

CONCLUSION

TB still becomes the main coinfection in HIV patients. It has uncertain clinical manifestations, unclear diagnosed, including the routine laboratory examinations. CD4+ count as one of laboratory testing generally conducted in HIV patients, often considered by physicians as predictor of TB form. It will reduce their concern while the patient has high level of CD4+ count. In fact, there is very low correlation between them.

Hopefully the physicians should be aware of TB in all its clinical staging, not only using CD4+ count as the predictor of the severity of TB in TB-HIV patients. As we treat the patients comprehensively, there are many other factors that influence the forms of TB. Hence, it is

needed to conduct other research to get more specific issues.

REFERENCES1. Sharma SK, Mohan A, Kadhiravan T. HIV-TB

coinfection: epidemiology, diagnosis & management. Indian J Med Res. 2005;121:550-67.

2. Sterling TR, Pham PA, Chaisson RE. HIV infection-related tuberculosis: clinical manifestation and treatment. Clin Infect Dis. 2010;50(Suplement 3):S223-30.

3. Attili VS, Singh VP, Rai M, Varma DV, Sundar S. Evaluation of the status of tuberculosis as part of the clinical case definition of AIDS in India. Postgrad Med J. 2005;81(956):404-8.

4. Canaday DH, Wu M, Lu S, Aung H, Peters P, Baseke J, et al. Induction of HIV type 1 expression correlates with T cell responsiveness to mycobacteria in patients coinfected with HIV type 1 and mycobacterium tuberculosis. AIDS Res Hum Retroviruses. 2009;25(2):213-6.

5. Badri M, Ehrlich R, Wood R, Pulerwitz T, Maartens G. Association between tuberculosis and HIV disease progression in a high tuberculosis prevalence area. Int J Tuberc Lung Dis. 2001;5(3):225-32.

6. SEARO. TB in South-East Asia. [diakses tanggal 8 Januari 2012, 19.00 WIB]. Diakses dari http://www.searo.who.int/en/Section10/Section2097/Section2100_10639.htm.

7. SEARO. Country profile: Indonesia. [diakses tanggal 8 Januari 2012, 19.00 WIB]. Diakses dari http://www.searo.who.int/en/Section10/Section2097/Section2100_14798.htm.

8. Widjanarko B, Gompelman M, Dijkers M, van der Werf MJ. Factors that influence treatment adherence of tuberculosis patients living in Java, Indonesia. Patient Prefer Adherence. 2009;3:231-8.

9. Ahmad RA. Improving tuberculosis case finding in Indonesia. 2011 [diakses tanggal 8 Januari 2012, 19.00 WIB]. Diakses dari http://repub.eur.nl/res/pub/30633/111206_Ahmed,%20Riris%20Andono_bewerkt.pdf.

10. Rewata L, Rutherford M, Apriani L, Janssen W, Rahmadi A, Parwati I, et al. Improving diagnosis of pulmonary tuberculosis among HIV/AIDS patients: literature review and experience in a teaching hospital in Indonesia. Acta Med Indones. 2009;41 (Suppl 1):57-64.

11. Demiralay R. Some epidemiological features of extrapulmonary tuberculosis registered in the tuberculous struggle dispensaries in Isparta. Tuberk Toraks. 2003;51(1):33-9.

12. Kuz’min OA, Turkin EN, Nikitina TN, Sergeeva EG. Tuberculosis and HIV infection in the Kaliningrad Region. Probl Tuberk Bolezn Legk. 2005;(10):37-40.

13. Algood HM, Philiana LL, Joanne LF. Tumor necrosis factor and chemokine interactions in the formation and maintenance of granulomas in tuberculosis. Clin Infect Dis. 2005:41(3):S189-S93.

14. Schulger N, William R. The host immune response to tuberculosis. Am J Respir Crit Care Med. 1998;157(3): 679-91.

Vol 44 • Number 2 • April 2012 The Correlation Between CD4+ T-lymphocyte Count and Tb Form

127

15. Vankayalapati. Serum cytokine concentrations do not parallel mycobacterium tuberculosis–induced cytokine production in patients with tuberculosis. Clin Infect Dis. 2003:36:24-9.

16. Rodwell TC, Richard FW, Marisa M, Steffanie AS, Annie R, Kathleen SM, et al. HIV-tuberculosis coinfection in Southern California: evaluating disparities in disease burden. Am J Public Health. 2010; 100(Suppl 1):S178–S85.

17. Kingkaew N, Sangtong B, Amnuaiphon W, Jongpaibulpatana J, Mankatittham W, Akksilp S, et al. HIV-associated extrapulmonary tuberculosis in Thailand: epidemiology and risk factors for death. Int J Infect Dis. 2009;13(6):722-9.

18. Forssbohm M, Wahlen MZ, Loddenkemper R, Rieder HL. Demographic characteristics of patients with extrapulmonary tuberculosis in Germany. ERJ. 2008;31(1):99-10.

19. Bhatt NB, Gudo ES, Semá C, Bila D, Di Mattei P, Augusto O, et al. Loss of correlation between HIV viral load and CD4+ T-cell counts in HIV/HTLV-1 coinfection in treatment naïve Mozambican patients. Int J STD AIDS. 2009;20(12):863-8.

20. Ong CK, Tan WC, Leong KN, Muttalif AR. Tuberculosis-HIV coinfection: The relationship between manifestation of tuberculosis and the degree of immunosuppression (CD4 counts). Iejsme. 2008; 2(2):17-22.

21. Agarwal D, Chakravarty J, Sundar S, Gupta V, Bhatia BD, Agarwal D, et al. Indian Ped. 2008:45 2(17):140-3.

22. Aderaye G, Haimanot G/Egziabher, Aseffa A, Worku A, Lindquist L. Comparison of acid-fast stain and culture for Mycobacterium tuberculosis in pre- and post-bronchoscopy sputum and bronchoalveolar lavage in HIV-infected patients with atypical chest X-ray in Ethiopia. Ann Thorac Med. 2007;2(4):154–15.

23. Warren JR, Bhattacharya M, Almeida KNF, Trakas K, Peterson LR. A minimum 5.0 ml of sputum improves the sensitivity of acid-fast smear for mycobacterium tuberculosis. Am J Respir Crit Care Med. 2000;161(5):1559-62.

24. Shea YR, Davis JL, Huang L, Kovacs JA, Masur H, Mulindwa F, et al. High sensitivity and specificity of acid-fast microscopy for diagnosis of pulmonary tuberculosis in an African population with a high prevalence of human immunodeficiency virus. J Clin Microbiol. 2009;47(5):1553-5.

25. Kumar S, Ferns S, Sujatha S, Jatiya L. Acid-fast staining patterns and their correlation with HIV positivity. Acta Cytol. 2005;49(1):111-2.

26. David M, BChir. The ESR in HIV: a neglected parameter? AIDS. 2010;24(18):2773–5.

27. Ukpe IS, Southern L. Erythrocyte sedimentation rate values in active tuberculosis with and without HIV coinfection. SAMJ. 2005;95(5):427-8.

28. Ndakotsu MA, Salawu L, Durosinmi MA. Relation between erythrocyte sedimentation rate, clinical and immune status in HIV-infected patients. Niger J Med. 2009;18(2):208-10.