Long-term HIV and tuberculosis outcomes in patients hospitalised with severe cutaneous adverse reactions

S Veenstra; M N Porter; B N Thwala; N Pillay; M A Panieri; J van der Westhuizen; E J Phillips; G Meintjes; S Dlamini; R J Lehloenya; J Peter

doi:10.1016/j.jctube.2023.100374

Long-term HIV and tuberculosis outcomes in patients hospitalised with severe cutaneous adverse reactions

J Clin Tuberc Other Mycobact Dis. 2023 May 8:32:100374. doi: 10.1016/j.jctube.2023.100374. eCollection 2023 Aug.

Authors

S Veenstra¹, M N Porter², B N Thwala², N Pillay³, M A Panieri³, J van der Westhuizen⁴, E J Phillips⁵, G Meintjes⁶, S Dlamini⁷, R J Lehloenya⁸, J Peter^{2

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Affiliations

¹ Department of Medicine, University of Cape Town, Groote Schuur Hospital, Observatory, Cape Town, South Africa.
² Division of Allergy and Clinical Immunology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.
³ Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
⁴ Community Services and Health, City Health, City of Cape Town, South Africa.
⁵ Centre for Drug Safety and Immunology, Departments of Medicine, Dermatology, Pharmacology and Pathology, Microbiology & Immunology, Vanderbilt University Medical Centre, Nashville, TN, USA.
⁶ Department of Medicine and Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
⁷ Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa.
⁸ Division of Dermatology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.
⁹ Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa.

Abstract

Background: Treatment-limiting severe cutaneous adverse reactions (SCAR) occur more commonly amongst persons with HIV-associated tuberculosis (TB). The impact of SCAR on long-term HIV/TB outcomes is unknown.

Methods: Patients with TB and/or HIV admitted to Groote Schuur Hospital, Cape Town, South Africa with SCAR between 1/10/2018 and 30/09/2021 were eligible. Follow-up data was collected for 6- and 12-month outcomes: mortality, TB and antiretroviral therapy (ART) regimen changes, TB treatment completion, and CD4 count recovery.

Results: Forty-eight SCAR admissions included: 34, 11, and 3 HIV-associated TB, HIV-only and TB-only patients with 32, 13 and 3 cases of drug reaction with eosinophilia and systemic symptoms, Stevens-Johnson syndrome/toxic epidermal necrolysis and generalised bullous fixed-drug eruption respectively. Nine (19%), all HIV-positive (eight co-infected with TB), were deceased at 12-months, and 12(25%) were lost to follow-up. Amongst TB-SCAR patients, seven (21%) were discharged on all four first-line anti-TB drugs (FLTD), while 12(33%) had regimens with no FLTDs; 24/37(65%) completed TB treatment. Amongst HIV-SCAR patients, 10/31(32%) changed ART regimen. If retained in care (24/36), median (IQR) CD4 counts increased at 12-months post-SCAR (115(62-175) vs. 319(134-439) cells/uL).

Conclusion: SCAR admission amongst patients with HIV-associated TB results in substantial mortality, and considerable treatment complexity. However, if retained in care, TB regimens are successfully completed, and immune recovery is good despite SCAR.

Keywords: CD4 count; DRESS; Drug allergy; Mortality; SJS/TEN; Viral load.