{'fraction_non_alphanumeric': 0.03384538528787311, 'fraction_numerical': 0.026976395653802922, 'mean_word_length': 4.832483612527312, 'pattern_counts': {'":': 0, '<': 1, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
PREVALENCE OF PULMONARY TUBERCULOSIS IN HIV POSITIVE INDIVIDUALS AND ITS ASSOCIATION WITH CD4 COUNT

PURPOSE: There is grave concern regarding increase in HIV associated Tuberculosis (TB) and emergence of Multi Drug Resistant (MDR) and Extremely Drug Resistant (XDR) TB. It is essential to know prevalence of TB in HIV patients and its association with CD4 count. MATERIAL & METHODS: A total of 362 patients were screened for Pulmonary TB of which 85 (23.48%) were diagnosed as Pulmonary TB by radiology, Ziehl Neelson (ZN) smear and culture. Results: It was commoner in males (28.76%), almost equal in urban (23.64%) & rural (22.45%) people and more frequent in laborers (34.12%). Culture was positive in 34 (40%) out of 85 Pulmonary TB patients of which 33 were M. tuberculosis and one was Rapid grower. The results of the study emphasize that coinfection of TB in HIV/AIDS patients is a concern. There is direct correlation between CD4 counts depletion and Pulmonary TB in HIV/AIDS patient. Hence, regular monitoring of these patients is warranted.

INTRODUCTION: AIDS, the Acquired Immunodeficiency Syndrome, is the disease known to be scourge for our century has had an impact like no other disease. Human Immunodeficiency Virus (HIV) affects the human Helper T lymphocytes and macrophages, which are important in maintaining cell mediated immunity (CMI). The CMI is essential in protecting persons from many diseases including tuberculosis. HIV is the most important known risk factor that promotes progression to active tuberculosis in people with Mycobacterium tuberculosis infection. 1 Tuberculosis (TB) and HIV have been closely linked since the emergence of AIDS. The lifetime risk of tuberculosis in immune competent persons is 5% to 10%, but in HIV positive individuals, there is a 5% to 15% annual risk of developing active TB disease. 2 The estimated prevalence of bacteriologically positive TB (Smear and/or culture) is 249 per 100,000 for India. 3 The pattern of clinical presentation of TB depends on the host immune status which is reflected in the microbiological, radiological and histological characteristics of TB.
The CD4 T-cell count is one of the best indicators of the immediate state of immunologic competence of the patient with HIV infection. The appearance of many opportunistic infections correlates with the CD4 count. TB generally develops at CD4 counts of 200-500 cells/mm. 3 Thus determinations of CD4 cell counts provide a powerful tool for determining prognosis and monitoring response to HAART. 4 Therefore the present study has been undertaken to know the prevalence of Pulmonary Tuberculosis (PTB) in HIV positive individuals, to diagnose pulmonary tuberculosis in HIV positive individuals using conventional staining methods (Ziehl Neelsen stain), culture (Lowenstein-Jensen) and radiological evidence, and to study the correlation of pulmonary tuberculosis with the CD4 cell counts in HIV positive individuals.

MATERIAL & METHODS:
The Prospective Hospital Based Study was conducted in the Department of Microbiology, from November 2007 to October 2009 in association with the ART clinic, Medicine, Integrated Counseling & Testing Centre, Chest and TB wards of our hospital.
A total of 362 known HIV positive patients of 18 years of age and above either hospitalized or coming to ART clinic, clinically suspected of having pulmonary tuberculosis, after written informed consent, were included in the study. The patients with extra pulmonary manifestations were excluded from the study.
Two sputum samples were obtained from each patient as per RNTCP guidelines. 5 Smears were prepared and stained by Ziehl Nielsen stain. The culture was done on Lowenstein-Jensen medium (LJ) The growth was identified by standard methods. 6 About 3 ml of blood was collected from each patient using aseptic precautions in EDTA vacutainers. CD4 counting of blood samples was done by Flow cytometry as per manufacturer's instructions (FACS Calibur, Becton-Dickinson, Immunocytometry system). The findings of the chest Xray were noted of each patient. Correlation of CD4 cell counts was done with the pulmonary tuberculosis in HIV positive patients.

RESULTS:
Out of 362 patients, a total of 85 (23.48%) were diagnosed as Pulmonary tuberculosis patients by radiology, Z.N. staining and culture. The tuberculosis patients according to their occupation are shown in Table 1.
Of the 85 Pulmonary tuberculosis cases 34(40.0%) were positive by culture and/or smear along with radiology and 51 (60.0%) were diagnosed by radiology alone. Table 2 shows the correlation between the results of Z. N. stain and Culture.
Of the total 85 PTB cases, in 34 (40%) patients Mycobacteria were isolated by culture. Of the 34 isolates 33 were M. tuberculosis complex and 1 was Rapid grower (Atypical Mycobacteria). Of the 85 Pulmonary tuberculosis cases 48 (56.47%) had CD4 counts of less than 200, in 28 (32.94%) between 200 & 349, in only 6 (7.06%) between 350 & 500 and in only 3 (3.53%) cases the CD4 counts were more than 500 cells/µl. The association of CD4 counts with occurrence of PTB is shown in Table 3.

DISCUSSION:
AIDS is a pandemic of 21 st century and pulmonary tuberculosis is the most common opportunistic infection (AIDSCAP). 7 it is important to identify PTB at an earliest so that it can be managed appropriately and at the right time. The prevalence of PTB among the HIV positive persons, in the present study is 23.48 per cent. The prevalence of co-infection with HIV varies widely across regions 8,9,10,11,12,13 within India and outside India mainly due to the variation in the distribution of risk factors, geographic location, awareness levels etc. of the study population.
In the present study, amongst these HIV/PTB co infected, as many as 29 (34.12%) were laborers by occupation followed by drivers 17 (20%). Thus laborers and drivers among AIDS patients had a significant association (p=0.023) with the risk of developing TB. Moreover, TB is still a disease of the poor and the low socio-economic background particularly among the developing countries.
The diagnosis of PTB is based on Radiological findings supplemented by the microbiology tests. The Z. N. stain is simple, economical and rapid but culture is more sensitive than staining. Besides this, culture enables us to identify the strain and also to do the susceptibility testing. The culture isolates in the present study were mostly M. tuberculosis.
The appearance of many opportunistic infections (OI's) correlates with the CD4 cell count. In PTB patients to the depletion of CD4 counts bear a direct correlation with acquisition of disease. Tuberculosis has a direct association with cell mediated immunity (CMI). The CD4 counts are an important indicator of CMI status of an individual. The data in the present study indicates that the patients with CD4 counts of less than 350/µl are at substantially higher risk of acquiring PTB. Similar correlation was reported by other Indian and foreign studies. 14,15,16 Since HIV/AIDS leads to immunosuppression, it is strongest of all known risk factors for development of TB. Thus, the patients who have CD4 count <350 cells/ μl have significantly more chances of acquiring TB (p=0.001) confirming further the importance ofCD4 counts.
Thus, the results of the present study emphasizes that co-infection of TB has been a major concern in HIV/AIDS patients. TB remains an important public health problem and has been exacerbated by the HIV epidemic, resulting in increased morbidity and mortality worldwide. HIV-TB co-infection is "Bidirectional and synergistic" and is often designated as "Cursed Duet". HIV/AIDS leads to immune suppression and is a strongest of all known risk factors for the development of TB and there is need for constant monitoring of HIV positive patients for acquisition of TB, assessment the type of prevalent mycobacteria in the region and information on the resistance pattern obtained in the prevalent strains.

Occupation
No. of patients (