La gestione della persona immigrata con coinfezione parte III

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1 La gestione della persona immigrata con coinfezione parte III
Tubercolosi, HIV e migrazione: una reale emergenza? SESSIONE II -ˇ HIV e Tubercolosi nella persona immigrata La gestione della persona immigrata con coinfezione parte III 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”

2 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)

3 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!)

4 ….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

5 Immune reconstitution inflammatory syndrome
AIDS PROGRESSION? Source: GHTM, Chennai

6 …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

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8 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 co-infection. MDR-TB rates in the civilian sector were respectively 15.5% (95%CI ) and 41.5% (95%CI ) in newly diagnosed and previously treated TB patients. Among prisoners, MDR-TB rates were 21.8% (95%CI ) in new cases and 52.8% (95%CI ) in previously treated TB cases. HIV status was significantly associated with MDR-TB (OR 1.7, 95%CI ). 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 drug-resistant TB and collaboration between HIV and TB control activities need to be implemented without further delay.

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10 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

11 Dopo 1 anno (2010) miglioramento clinico e laboratoristico
TC Ott 2010: quadro stabile CD4: 188 cell/mmc, HIV-RNA<50, Hb=14

12 HCV/HIV scenario 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: Genotipo 3 HCV/HIV scenario

13 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] %). 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 ) and blood transfusions (odds ratio 3.2, 95% CI ) 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

14 Ultimo controllo DH 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

15 La lunga storia di Sergej
Dic. 2006: diagnosi HIV Feb. 2007: diagnosi TB, unmasked TB Apr. 2007: IRIS Lug. 2007: pneumotorace Mag 2008: zoster multimetamerico Gen. 2009: TB linfonodale, resistenza a INH Gen. 2010: TB localizzazione ossea, colliquazione linfonodale Gen. 2011: sospende terapia per TB Mar. 2011: riattivazione HCV STP……. ART TB therapy Ricoveri degenza/ domicilio STP……. DH/DOT STP…….

16 La lunga storia di Sergej: “la morale”
TB/HIV/migrazione ci impone: 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

17 Grazie per l’attenzione!
Спасибі за Вашу увагу! Nevicata sulla spiaggia di Terracina