Tubercolosi, HIV e migrazione: una reale emergenza?
SESSIONE II -ˇ HIV e Tubercolosi nella persona immigrata
Miriam Lichtner
Dipartimento di Malattie Infettive e Sanità Pubblica
Sapienza Università di Roma Polo Pontino
Componente dell’ Italian National Focal Point –
Infectious Diseases and Migrant”
Sergej
• Dopo pochi mesi di ART:
• Genotipo HIV: resistenza a 3TC e NNRTI
• Cambio ART: truvada + kaletra con adattamento
terapia anti-TB (DA rifampicin A rifabutina)
Luglio 2007: nuovo ricovero (centro Hub)
(17/07/07-25/07/07)
• Pneumotorace dx
• Posizionamento drenaggio pleurico, poi
rimosso
• Prosegue a domicilio la terapia a 4 farmaci
anti-TB + kaletra+truvada+bactrim+folina:
Totale pillole: 17!!!!al giorno (pill burden!)
….dopo un anno (6/05/2008)
: nuovo ricovero (centro Hub)
•
•
•
•
Zoster multimetamerico, coscia, gluteo,sacro
Trattamento con aciclovir
21/05/2008:dimissione
Continua
nicozid+mycobutin+truvada+kaletra+bactrim
• CD4+: 87 ; HIVRNA<50
85
HERPES ZOSTER
81
TUBERCULOSIS
72
CMV RETINITIS
31
PCP
28
CRYPTOCOCCOSIS
HANSEN'S
3
OTHERS
3
Source: GHTM, Chennai
…dopo 6 mesi : nuovo ricovero al PS
• Dic 2008 (2 anni di antiTB): accesso al PS di Terracina per
Linfoadenopatia sovraclaveare, cachessia (47 Kg)
• Trasferimento al SM Goretti di Latina, UOC Mal. Infettive
• Es del pus:
– Esame DIRETTO: rari BAAR
– Esame in PCR: pos
– COLTURALE: neg
• Si documenta RESISTENZA a isoniazide in PCR
• TB gold indeterminato, HIV<40; CD4+: 120
• TC torace (gen 2009): “linfodenopatia diffusa mediastinica a colata
con consolidamento parenchimale, lesioni spleniche multiple”
• Si propone ricovero, ma pz rifiuta, si apre DH
Int J Tuberc Lung Dis. 2008 Jul;12(7):756-62.
Drug-resistant tuberculosis and HIV in Ukraine: a threatening convergence of two
epidemics?
Dubrovina I, Miskinis K, Lyepshina S, Yann Y, Hoffmann H, Zaleskis R, Nunn P, Zignol M.
OBJECTIVE:
To investigate anti-tuberculosis (TB) drug resistance rates in Donetsk Oblast, Ukraine, and to
explore the association between the epidemics of human immunodeficiency virus (HIV) and
multidrug-resistant TB (MDR-TB).
METHODS:
All consecutive newly diagnosed and previously treated patients with sputum smear-positive TB
presenting to all TB units in Donetsk Oblast over 12 months were invited to take part in the study. A total
of 1293 and 203 patients with TB were tested for HIV and MDR-TB in the civilian and penitentiary sectors,
respectively.
RESULTS:
Of those enrolled for the study, 307 were HIV-positive, 379 had MDR-TB, and 97 had MDR-TB and HIV coinfection. MDR-TB rates in the civilian sector were respectively 15.5% (95%CI 13.1-17.8) and 41.5% (95%CI
36.4-46.5) in newly diagnosed and previously treated TB patients. Among prisoners, MDR-TB rates were
21.8% (95%CI 12.4-31.2) in new cases and 52.8% (95%CI 43.9-61.7) in previously treated TB cases. HIV
status was significantly associated with MDR-TB (OR 1.7, 95%CI 1.3-2.3).
CONCLUSIONS:
High MDR-TB rates and a positive association between MDR-TB and HIV epidemics were
found in Donetsk Oblast. Urgent measures to improve HIV prevention, control of drugresistant TB and collaboration between HIV and TB control activities need to be implemented
without further delay.
Ricovero in DH a Latina (2009)
• Inizia “semi”DOT terapia: sospende isoniazide
continua rifabutina, reinizia
etanbutolo+piraldina+levofloxacina+amikacina
• Inizia supplemento nutrizionale
• Inizia terapia steroidea
Dopo 1 mese: miglioramento clinico
• Giugno: riaccensione psoriasi
• Dicembre: chiusura completa della fistola
Dopo 1 anno (2010)
• miglioramento clinico e laboratoristico
• TC Ott 2010: quadro stabile
• CD4: 188 cell/mmc, HIV-RNA<50, Hb=14
2011
• Pz sta clinicamente bene, 60 Kg
• HIV<50, CD4 = 166
• Sospende terapia anti-TB, continua Bactrim,
folina, truvada, kaletra
• GOT e GPT in aumento (Epatite cronica)
• HCV-RNA: 190.370
• Genotipo 3
Am J Gastroenterol. 2008 Apr;103(4):922-7.
High prevalence of hepatitis C virus infection among immigrants from the former Soviet Union in
the New York City metropolitan area: results of a community-based screening program.
Batash S, Khaykis I, Raicht RF, Bini EJ.
Source
Division of Gastroenterology, NYU School of Medicine, New York, New York, USA.
Abstract
BACKGROUND:
Inadequate sterilization and reuse of medical equipment likely contributed to hepatitis C virus (HCV) transmission in the former
Soviet Union (FSU). Although New York leads the nation in the number of immigrants from the FSU, the epidemiology of HCV
infection has not been evaluated in this population. The aims of this study were to determine the prevalence of and risk factors for
HCV infection among immigrants from the FSU in the New York metropolitan area.
METHODS:
We conducted a 3-day community-based HCV screening program in the two boroughs of the New York metropolitan area with the
highest density of FSU immigrants (Brooklyn and Queens). Russian cable television was used to invite subjects to come in for free
HCV testing. In the last 2 days of screening, each person also completed an HCV risk factor questionnaire.
RESULTS:
The overall prevalence of HCV seropositivity among the 283 subjects was 28.3% (95% confidence
interval [CI] 23.0-33.5%). The prevalence of HCV infection was similar in men and women (30.3% vs
26.5%, P = 0.48) and was highest in subjects > or = 70 yr old (35.0%). HCV seropositivity was 11.1%
in immigrants from Russia, 29.0% from Uzbekistan, 31.0% from the Ukraine, and 36.8% from other
regions. Intramuscular injections (odds ratio 9.1, 95% CI 2.0-42.4) and blood transfusions (odds
ratio 3.2, 95% CI 1.2-9.0) were the only variables that were significantly associated with HCV
infection in the multivariable analysis.
CONCLUSIONS:
In this community-based screening program we found a high prevalence of HCV infection among
immigrants from the FSU, and these infections likely resulted from inadequately sterilized medical
equipment and blood transfusions. Universal HCV testing should be strongly considered for all FSU
immigrants
Ultimo controllo DH
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Sergej inizia a parlare un po’ di italiano
Sergej ha iniziato a lavorare
È sempre irregolare
Ha sempre il tesserino STP
Viene regolarmente ai controlli e a ritirare i
farmaci
La lunga storia di Sergej
• Dic. 2006: diagnosi HIV
STP…….
• Feb. 2007: diagnosi TB, unmasked TB
• Apr. 2007: IRIS
• Lug. 2007: pneumotorace
• Mag 2008: zoster multimetamerico
Ricoveri degenza/
domicilio
STP…….
• Gen. 2009: TB linfonodale, resistenza a INH
• Gen. 2010: TB localizzazione ossea,
colliquazione linfonodale
DH/DOT
• Gen. 2011: sospende terapia per TB
• Mar. 2011: riattivazione HCV
T
B
STP…….
A
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a
p
y
La lunga storia di Sergej: “la morale”
• Di contestualizzare il paziente nel suo contesto di provenienza
• Di lavorare in rete
• Di trovare una gestione clinica prolungata che supporti l’aderenza
alle cure
• Di fornire gli strumenti al paziente per comprendere le cure
• Di seguire sempre l’aspetto clinico complessivo
• Di avvalersi di metodologie innovative (PCR, TB gold, radiologia
avanzata..)
• Di preservare il nostro SSN che ci permette tutto questo
NONOSTANTE TUTTO
Nevicata sulla spiaggia di Terracina