Book Title: Tuberculosis in Immunocompromised Patients
Author: Dr. Iddah Ali
Publisher: Lambert Academic Publishing
Book Reviewer: Wangari Njoroge
Tuberculosis in Immunocompromised Patients offers comprehensive insight bridging the critical gap between co-infections of Tuberculosis and HIV/AIDs.
In the battle against tuberculosis (TB) and HIV co-infections, Africa bears a staggering burden, with Kenya grappling as an epicenter, with up to 60% of TB patients in Kenya co-infected with HIV and the increasing mortality rates inadvertently being attributed to TB.
Dr. Iddah Ali, Chair of the Department of Medical Microbiology & Parasitology at Masinde Muliro University of Science and Technology, tailored this great handbook for researchers in the field of tuberculosis, clinicians, and diagnostic technicians as it emerges as an indispensable resource for those navigating the complicated field of HIV-associated and drug-resistant TB.
Within its pages is a great wealth of knowledge shaping a narrative aimed at solving the complexities of the TB global health challenge.
The compelling Foreword penned by Professor John Okutoyi Wambani, Dean School of Health Science at Alupe University College, states that Dr. Ali’s work highlights the challenges faced in Africa, particularly the alarming intersection of HIV and tuberculosis, which stands as a primary cause of mortality in resource-limited settings.
The Foreword equally underscores the changing nature of tuberculosis, emphasizing the pressing need for innovative diagnostic approaches in the face of altered clinical presentations due to HIV infections.
“This is the first edition of Tuberculosis in Immunocompromised Patients and it provides an excellent tool for those working to treat and finally defeat tuberculosis, covering all aspects from pathology through to diagnosis, treatment, control and prevention,” distinguished Prof. Wambani.
Styles of writing
Dr. Ali’s “Tuberculosis in Immunocompromised Patients” is a meticulously researched educational handbook curated for a specific audience seeking profound guidelines and information.
The book delves into complex medical intricacies, particularly the intersection of TB and HIV/AIDS, utilizing a robust jargon of medical terminologies, which perfectly suits the book’s target audience.
Additionally, the author ensures credibility by citing references from renowned scholars and fortifying her work with specific and accurate facts.
She gives factual numbers and, at the end of each chapter, does a bibliography and literature review of the scholars, books, and sources leveraged in that particular chapter.
What sets this book apart is the strategic use of well-labeled diagrams, for example, on pages 7, 30, 38, and 64, offering readers visual aids that break the monotony and enhance comprehension.
Structured with precision, the 93-page book unfolds across 10 chapters, each subdivided into digestible sub-topics; this thoughtful organization promotes a seamless flow of knowledge, facilitating easy consumption for readers navigating the sensitive field of immunocompromised patients and tuberculosis.
Introduction
The introductory book chapter delves into the roots and progression of tuberculosis caused by the mycobacterium tuberculosis complex, which includes M. tuberculosis, M. bovis, M. africanum, M. microtys, and M. canetti and spread through airborne particles.
According to Dr. Ali, TB primarily targets the lungs, often leaving local scarring termed as the primary complex.
However, it can disseminate, leading to Milliary spread and waning immunity may prompt reactivation, particularly in HIV patients who might experience asymptomatic diseases, thus decreasing their immunity.
In resource-limited regions, where access to Antiretroviral Treatment (ART) is a challenge, the said co-infection of HIV and tuberculosis stands as the predominant cause of mortality among HIV-infected individuals.
Dr. Ali reveals that a stark reality in 2010 exposed 350,000 tuberculosis-related deaths in HIV-positive populations, primarily concentrated in developing nations, notably sub-Saharan Africa; with an estimated 22.5 million people living with HIV in this region, the symbiotic relationship between these two diseases poses a worrying challenge.
“Co-infection between HIV and tuberculosis is the leading cause of death in patients infected with HIV living in resource limited countries accessing antiretroviral treatment (ART) programmes,” she states in the introduction.
Between the chapters
Dr. Ali, in depth, discusses Tuberculosis from its immunology, microbiology, types of tuberculosis and risks exposure, especially to people who are immunocompromised.
This chapter, the details of Mycobacterium tuberculosis and the human immune system are illustrated with diagrams on the pages.
The immunology of TB reveals that the majority of those infected never succumb to the clinical disease, showcasing the efficacy of the innate and adaptive immune response.
However, the interplay of TB and HIV complicates matters; HIV’s reduction of CD4+ T cells weakens immunity, impacting the strength of the cellular immune response known as the granuloma.
Conversely, TB influences HIV progression to AIDS, forming a complex web.
The immunological mechanism of how both TB and HIV influence the progression of each other is discussed in detail on Page 5.
Dr. Ali, on page 6, explores how M. tuberculosis evades the immune system’s scrutiny, modulating antigen-presenting cells and resisting reactive oxygen intermediates.
Between chapters 2-6, the author exclusively discusses the microbiology and pathogenesis of Mycobacterium tuberculosis, the second leading cause of infectious death globally.
She outlines the natural history of infection, including immediate clearance, latent infection and the development of active tuberculosis.
For immunocompromised patients, Dr. Ali also states that there are risks of TB affecting the kidneys and the Urinary Tract System.
There are diverse renal complications associated with tuberculosis, including direct kidney infection, secondary amyloidosis, nephrotoxicity from medications and urinary tract involvement.
Emphasizing the heightened risk for HIV patients, the book further discusses clinical manifestations, complications, and diagnostic challenges.
BCG vaccination
Primarily, BCG vaccine prevents one from getting infected with TB from a young age.
The book notes that the durability of BCG-induced protection is generally around 10 to 15 years, with some instances demonstrating lasting potency for up to 50 to 60 years.
In this chapter, the author delves into critical aspects of BCG vaccination, addressing issues of host immunity, vaccine efficacy, administration, safety and policy considerations.
Notably, prior mycobacterial infections, whether acquired naturally or through vaccination, contribute to varying levels of protection against tuberculosis and related infections.
However, areas of uncertainty persist, particularly regarding BCG’s effectiveness in drug-resistant tuberculosis, and there is a lack of definitive prospective data for specific groups such as healthcare workers or world travelers who might be more exposed to infections.
She also advises against vaccinating immunocompromised patients stating, “BCG vaccination should not be administered to individuals with immune compromise due to HIV infection, congenital immunodeficiency, malignancy, or immunosuppressive drugs. Adults with HIV infection and individuals with HIV infection in areas of low TB prevalence should NOT receive BCG vaccination (WHO, 2004).”
In the next chapter, she advices on transmission and control of tuberculosis through use of masks, laboratory evaluation, room management and inpatient and outpatient management too.
Diagnostic challenges
The last chapter of ‘Tuberculosis in Immunocompromised Patients’ highlights challenges in diagnosing tuberculosis particularly in HIV-infected individuals.
Dr. Ali notes that traditional methods like direct smear microscopy exhibit reduced sensitivity in HIV co-infections, leading to false negatives.
On the other hand, chest radiography, while common, has variable accuracy, especially in severely immune-compromised HIV patients.
She explains how culture, despite being considered a gold standard, has slow results and reduced effectiveness in paucibacillary disease.
Dr. Ali acknowledged that the pressing need for quicker, more accurate diagnostics led to the emergence of molecular techniques like Polymerase Chain Reaction (PCR) and the Xpert MTB/RIF assay, endorsed by the World Health Organization (WHO).
The two address limitations in diagnosis in areas of sensitivity, specificity, and turnaround time, crucial for timely TB diagnosis in high HIV prevalence regions.
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The comprehensive educational book concludes with a glossary providing explanations for the medical terms used throughout which enhances accessibility for readers beyond the intended audience and ensuring clear comprehension of its content.
