Pulmonary tuberculosis in AIDS patients: Transient chest radiographic worsening after initiation of antiretroviral therapy

OBJECTIVE. Immune function and inflammatory responses often increase in AIDS patients who receive antiretroviral therapy. We evaluated the occurrence and nature of transient worsening on chest radiographs in AIDS patients with tuberculosis after initiation of antiretroviral therapy and compared these findings with chest radiographs of patients undergoing antituberculous therapy alone. MATERIALS AND METHODS. A retrospective review of sequential chest radiographs was performed of 87 patients undergoing therapy for pulmonary tuberculosis: AIDS patients receiving antiretroviral therapy (n = 31), HIV-positive patients not receiving antiretroviral therapy (n = 26), and HIV-negative patients (n = 30). Pulmonary consolidations, thoracic lymphadenopathy, and pleural effusions were evaluated for worsening, stability, or improvement. Patients with concurrent pulmonary infections were excluded. RESULTS. Transient worsening on radiography was observed in 14 (45%) of 31 AIDS patients receiving antiretroviral therapy, including seven patients (23%) who showed severe worsening, Of 56 patients in the other two groups, 11 (20%) showed worsening (p = 0.023), two of whom showed severe worsening (p = 0.009). Worsening was first noted between 1 and 5 weeks after initiation of antiretroviral therapy, with improvement occurring between 2 weeks and 3 months later. Four patients with severe worsening converted their tuberculin pu rifled protein derivative responses from anergic to positive after antiretroviral treatment. CONCLUSION. Transient worsening is frequently seen on chest radiography in AIDS patients with tuberculosis who subsequently undergo antiretroviral therapy. This phenomenon may be related to improved immune function.