Tuberculosis and Acquired Immunodeficiency Syndrome -- Florida

In 1985, 1,425 tuberculosis cases were reported in Florida, an increase of almost 7% over the 1,335 cases reported in 1984. Concern about a possible association between human T-lymphotropic virus type III/lymphadenopathy-associated virus (HTLV-III/LAV)* infection and increased tuberculosis morbidity (1,2) led to an evaluation of data on acquired immunodeficiency syndrome (AIDS) and tuberculosis. Four subgroups of persons were identified and their characteristics compared: (1) AIDS patients with and without tuberculosis (AIDS/TB and AIDS/non-TB, respectively), and (2) tuberculosis patients with and without AIDS (TB/AIDS and TB/non-AIDS, respectively). The overlapping subgroups of AIDS/TB and TB/AIDS are listed separately only because their characteristics were analyzed from two discrete data bases. AIDS PATIENTS WITH AND WITHOUT TUBERCULOSIS

Of the 1,094 persons meeting the CDC surveillance definition of AIDS (3) reported from Florida in the period 1981-1985, 109 (10%) were also diagnosed in the period 1978-1985 as having tuberculosis.** The number of AIDS patients with tuberculosis by year of AIDS diagnosis rose progressively from zero in 1981 to a peak of 55 in 1984; this number fell to 26 in 1985. The interval between report of tuberculosis and diagnosis of AIDS ranged from 7 years before to 15 months after AIDS was diagnosed (median interval, 3 months before AIDS diagnosis). Sixty-two (57%) of the patients were reported to have tuberculosis more than 1 month before they were diagnosed as having AIDS; 30 (28%), within a month before or after they were diagnosed as having AIDS; and 17 (16%), more than a month after they were diagnosed as having AIDS.

AIDS/TB patients were similar to AIDS/non-TB patients with respect to age and sex (Table 3). However, AIDS/TB patients were more frequently black (81%) than were AIDS/non-TB patients (37%), were more frequently foreign born (60% versus 25%), and were less frequently homosexual or bisexual men (21% versus 62%). TUBERCULOSIS PATIENTS WITH AND WITHOUT AIDS

Of the 7,241 persons in Florida reported to have tuberculosis in the period 1981-1985, 105 (2%)S also had AIDS. The number and proportion has generally continued to rise, e.g., in 1981, five (less than 1%) of 1,553; in 1984, 33 (3%) of 1,335; the number fell to 23 (2%) of 1,425 in 1985. Of the 105 TB/AIDS patients, 65 (60%) were reported to have tuberculosis while residing in Dade County; and 23 (22%), while residing in Palm Beach County. Compared with TB/non-AIDS patients, TB/AIDS patients were younger (median 30 years versus 49 years) and were more often black (79% versus 51%), male (83% versus 71%), and foreign born (60% versus 21%). TB/AIDS patients were also more likely to have extrapulmonary tuberculosis (38% versus 11%), particularly lymphatic and miliary forms, while pleural tuberculosis was extremely rare (Table 4). Reported by CH Cole, MD, JJ Witte, MD, WJ Bigler, PhD, BJ Sayer, DJ Garrity, Florida Dept of Health and Rehabilitative Svcs; AIDS Program, Center for Infectious Diseases, Div of Tuberculosis Control, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The total number of AIDS patients in the United States meeting the CDC surveillance case definition represents only a fraction of the number of persons with HTLV-III/LAV infection. It has been estimated that, in 1985, for every case of AIDS, there were 50-100 persons with HTLV-III/LAV infection (4). The number of tuberculosis patients with HTLV-III/LAV infection but without AIDS may also exceed the number who have overt AIDS. The fact that tuberculosis did not decline in the nation as a whole in 1985 and the increase in the incidence of tuberculosis in certain areas may be partly explained by the infection with HTLV-III/LAV of persons who already had tuberculous infection (2). There are an estimated 10 million persons with latent tuberculous infection in the United States and as many as 1.5 million persons with HTLV-III/LAV infection (4). The degree to which these two infected populations overlap may be a factor in the number of tuberculosis cases that develop.

The fact that 10% of AIDS patients from Florida have been diagnosed as having tuberculosis suggests an association between AIDS and tuberculosis. Most of the tuberculosis among the AIDS patients may represent reactivation of latent tuberculous infection acquired in years past rather than progression from recently acquired infection. Immunodeficiency caused by HTLV-III/LAV infection probably allows latent tuberculous infection to progress to clinical tuberculosis. However, radiographically, the presentation of tuberculosis in AIDS patients is often indistinguishable from primary forms of the disease as seen in patients without AIDS (5). Thus, recently acquired tuberculous infection in this population cannot be ruled out.

The risk that persons with latent tuberculous infection who acquire AIDS (or HTLV-III/LAV infection without AIDS) will develop clinically active tuberculosis cannot be quantified from currently available data. However, the 10% incidence of clinically overt tuberculosis is substantially higher than would be expected for any other group, including tuberculin-positive contacts of tuberculosis cases (6).

The reason for the decreased number of TB/AIDS patients reported from Florida in 1985 is unknown. It may represent reporting artifact or a decline in the number of susceptible individuals at risk.

Other health departments may wish to determine the degree to which tuberculosis morbidity is associated with AIDS and the prevalence of HTLV-III/LAV infection in tuberculosis patients. As recommended in recently published guidelines, as part of the evaluation of patients with tuberculosis, risk factors for HTLV-III/LAV should be identified (7). Voluntary testing of all persons with these risk factors is also recommended. In addition, testing for HTLV-III/LAV antibody should be considered for patients of all ages who have severe or unusual manifestations of tuberculosis. Such additional studies would help to determine the magnitude of the AIDS/TB problem in other areas and further define the population characteristics of persons with both tuberculosis and HTLV-III/LAV infection (with and without AIDS).

Treatment of tuberculosis patients who also have AIDS or HTLV-III/LAV infection should be instituted in accordance with recently published guidelines (7). Prevention of tuberculosis among persons with HTLV-III/LAV infection will require the identification of both HTLV-III/LAV and tuberculous infection and the administration of isoniazid preventive therapy as currently recommended (7). Counseling of persons being tested for HTLV-III/LAV infection should be provided in accordance with current recommendations to prevent the transmission of HTLV-III/LAV (8).

References

1. CDC. Tuberculosis--United States, first 39 weeks, 1985. MMWR 1985;34:625-7.

2. CDC. Tuberculosis--United States, 1985--and the possible impact of human T-lymphotropic virus type III/lymphadenopathy-associated virus infection. MMWR 1986;35:74-6.

3. CDC. Revision of the case definition of acquired immunodeficiency syndrome for national reporting--United States. MMWR 1985;34:373-5.

4. Curran JW, Morgan WM, Hardy AM, Jaffe HW, Darrow WW, Dowdle WR. The epidemiology of AIDS: current status and future prospects. Science 1985;229:1352-7.

5. Pitchenik AE, Rubinson HA. The radiographic appearance of tuberculosis in patients with the acquired immune deficiency syndrome (AIDS) and pre-AIDS. Am Rev Respir Dis 1985;131:393-6.

6. Comstock GW. Frost revisited: the modern epidemiology of tuberculosis. Am J Epidemiol 1975;101:363-82.

7. CDC. Diagnosis and management of mycobacterial infection and disease in persons with human T-lymphotropic virus type III/lymphadenopathy-associated virus infection. MMWR 1986;35:448-52.

8. CDC. Additional recommendations to reduce sexual and drug abuse-related transmission of human T-lymphotropic virus type III/lymphadenopathy-associated virus. MMWR 1986;35:152-5. *Subcommittee of the International Committee for the Taxonomy of Viruses has proposed that HTLV-III/LAV be officially designated as "Human Immunodeficiency Virus" or HIV. **These time intervals were chosen because AIDS was first recognized nationally in 1981 and because it was noted that the diagnosis of tuberculosis often preceded the diagnosis of AIDS by months or years. SThe other four of the 109 mentioned earlier in this report had been reported to have tuberculosis before 1981, when no detailed information on individual cases was available; they were therefore excluded from this analysis.

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