Outcomes of Comprehensive Care for Children Empirically Treated for Multidrug-Resistant Tuberculosis in a Setting of High HIV Prevalence

Abstract

Background

Few studies have examined outcomes for children treated for multidrug-resistant tuberculosis (MDR-TB), including those receiving concomitant treatment for MDR-TB and HIV co-infection. In Lesotho, where the adult HIV seroprevalence is estimated to be 24%, we sought to measure outcomes and adverse events in a cohort of children treated for MDR-TB using a community-based treatment delivery model.

Methods

We reviewed retrospectively the clinical charts of children ≤15 years of age treated for culture-confirmed or suspected MDR-TB between July 2007 and January 2011.

Results

Nineteen children, ages two to 15, received treatment. At baseline, 74% of patients were co-infected with HIV, 63% were malnourished, 84% had severe radiographic findings, and 21% had extrapulmonary disease. Five (26%) children had culture-confirmed MDR-TB, ten (53%) did not have culture results available, and four (21%) subsequently had results indicating drug-susceptible TB. All children with HIV co-infection who were not already on antiretroviral therapy (ART) were initiated on ART a median of two weeks after the start of the MDR-TB regimen. Among the 17 patients with final outcomes, 15 (88%) patients were cured or completed treatment, two (12%) patients died, and none defaulted or were lost to follow-up. The majority of patients (95%) experienced adverse events; only two required permanent discontinuation of the offending agent, and only one required suspension of MDR-TB treatment for more than one week.

Conclusions

Pediatric MDR-TB and MDR-TB/HIV co-infection can be successfully treated using a combination of social support, close monitoring by community health workers and clinicians, and inpatient care when needed. In this cohort, adverse events were well tolerated and treatment outcomes were comparable to those reported in children with drug-susceptible TB and no HIV infection.

About the Authors:

Hind Satti

* E-mail: [email protected]

Affiliations Partners In Health, Maseru, Lesotho, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America

Megan M. McLaughlin

Affiliations Partners In Health, Maseru, Lesotho, Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America

David B. Omotayo

Affiliation: Partners In Health, Maseru, Lesotho

Salmaan Keshavjee

Affiliations Partners In Health, Maseru, Lesotho, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America, Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America

Mercedes C. Becerra

Affiliations Partners In Health, Maseru, Lesotho, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America, Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America

Joia S. Mukherjee

Affiliations Partners In Health, Maseru, Lesotho, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America, Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America

Kwonjune J. Seung

Affiliations Partners In Health, Maseru, Lesotho, Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America

Introduction

Between 2000 and 2009, there have been an estimated five million new cases of multidrug-resistant tuberculosis (MDR-TB), defined as resistance to isoniazid and rifampicin. 3.5 million patients received no treatment or treatment of unknown quality, and 1.5 million died [1]. An estimated 10% to 15% of these patients were children [2]. Pediatric MDR-TB is often a result of primary resistance transmitted from adults with MDR-TB, rather than secondary resistance acquired as a result of suboptimal therapy [3], [4]. Thus, unlike adult MDR-TB prevalence, which often reflects the failure of national TB control programs, pediatric MDR-TB surveillance reveals ongoing transmission of MDR-TB in the community.

Pediatric tuberculosis presents several unique diagnostic and treatment challenges. Treatment delay is particularly problematic for children with MDR-TB, and outcomes are poor when treatment is delayed [5], [6]. Because of the difficulty of obtaining sputum from young children [7] and their tendency to have paucibacillary TB [6], [7], children are less likely to have culture confirmation of TB [8]–[10]. Thus, drug-susceptibility testing (DST) is often not possible [5], and the decision to initiate second-line TB therapy in children with clinical and radiographic evidence of TB disease must be made based on the patients’ TB history [11]–[13].

Additional challenges arise when diagnosing and managing MDR-TB in the context of HIV co-infection. Poor response to first-line TB treatment in HIV co-infected patients can occur for reasons other than drug resistance, including poor adherence and the presence of other opportunistic infections with pulmonary manifestations, and HIV co-infected patients are at increased risk of recurrent TB infections [14], [15]. Moreover, patients failing first-line TB treatment are often hospitalized in facilities lacking in infection control, putting the patient at risk of being re-infected with circulating drug-resistant TB strains or transmitting TB to others. Outbreaks of MDR-TB among HIV patients in health facilities have been well-documented [16]–[21], including a nosocomial outbreak in a pediatric ward [22]. Additionally, optimal timing of antiretroviral therapy (ART) initiation relative to second-line TB therapy is unknown [23]. Patients on treatment for both HIV and MDR-TB face a high pill burden, and little is known about the frequency and severity of adverse events from concomitant treatment, particularly in children [22]–[24].

A small number of studies and case series have examined outcomes for children treated for MDR-TB [6], [25]–[32]. Taken together, these suggest that when appropriate treatment–including individualized regimens and strong supervision and support–is initiated early, favorable treatment outcomes can be achieved in pediatric MDR-TB patients. However, there are few reports of DR-TB/HIV co-treatment in pediatric patients [22], [30], [31].

We sought to describe the clinical features, treatment course, and final outcomes in a cohort of children treated for MDR-TB in Lesotho using a community-based treatment delivery model.

Methods

Ethics Statement

As this was a retrospective study of medical information previously collected in the course of routine clinical care, informed consent was not required. This study was approved by the Partners HealthCare Human Research Committee.

Setting

Lesotho is a small, mountainous country completely surrounded by South Africa, with a population of approximately 1.8 million. Lesotho has a high burden of both HIV and TB: 24% of the adult population is HIV infected [33], and the estimated prevalence of TB is 402 cases per 100,000 population [34]. Among TB patients, an estimated 77% are co-infected with HIV [34]. Since 2007, the Lesotho Ministry of Health and Social Welfare (MOHSW), with support from Partners In Health, has operated a national MDR-TB program offering comprehensive, community-based treatment, free of charge to patients and their families. Partners In Health is a non-governmental organization that has worked in partnership with local communities and governments to provide health care access to a combined population of 2.4 million people in 12 countries, including more than 13,000 MDR-TB patients in Peru, Russia, Kazakhstan, and Lesotho [35].

Study Design

We conducted a retrospective analysis of medical charts of all patients ages 15 years or younger who initiated second-line TB treatment for confirmed or suspected MDR-TB between July 27, 2007 and January 1, 2011. We excluded one patient who began an MDR-TB regimen and was subsequently switched to first-line tuberculosis treatment based on drug-susceptibility testing (DST) results, patient history, and clinical and radiographic response to MDR-TB treatment.

Treatment Strategy

Treatment protocols, including pediatric dosing, followed international standards of care [25], [36]–[38]. In general, patients were referred by clinicians working in the MOHSW network of hospitals and health centers to the Lesotho national MDR-TB program for evaluation of confirmed or suspected MDR-TB. At the time of initial evaluation, sputum or lymph node specimens were collected and sent for DST. While awaiting DST results, a child was initiated on an empiric regimen with second-line TB drugs if he or she met the following criteria: 1) the child had clinical and radiographic evidence of TB disease, and 2) the child was either a household contact of a patient with confirmed or presumed MDR-TB, or the child had failed at least one supervised first-line regimen. The protocol for initiating empiric treatment has been described in detail previously [39]. Empiric regimens consisted of six drugs–pyrazinamide, capreomycin (or kanamycin), levofloxacin (or moxifloxacin or ofloxacin), ethionamide (or prothionamide), cycloserine, and para-aminosalicylic acid (PAS). When DST results of the patient or household source case were available or when a patient had received second-line drugs previously, treatment regimens were modified accordingly.

The management of patients who were started empirically on MDR-TB treatment and subsequently had DST results indicating susceptibility to isoniazid and rifampicin was considered on an individual case-by-case basis. Based on the patient’s clinical history, duration of MDR-TB treatment, and treatment response, the clinical team decided whether to transfer the patient to the local health center to receive first-line TB treatment or maintain the patient on the second-line regimen with the addition of rifampicin and high-dose isoniazid.

Lesotho experienced an uninterrupted supply of second-line antituberculous drugs during the study period. Because none of antituberculous drugs used in the standard regimen were available in pediatric formulations, patients were provided with adult formulations, and the clinicians and community health workers instructed caregivers to divide doses and cut tablets into the appropriate size.

Patients with unknown HIV serostatus were offered testing at the first visit. All patients with HIV co-infection who were not yet receiving ART were initiated on an ART regimen as soon as they were tolerating the MDR-TB treatment regimen, regardless of CD4 cell count. The standard ART regimen consisted of two nucleoside reverse transcriptase inhibitors (zidovudine or stavudine plus lamivudine) and one non-nucleoside reverse transcriptase inhibitor (efavirenz, or nevirapine for children under three years of age). All patients received pyridoxine supplementation to prevent peripheral neuropathy [40].

MDR-TB treatment was provided in the community for patients in stable, ambulatory condition. Trained, paid community health workers (CHWs) delivered second-line antituberculous drugs and antiretroviral therapy twice-daily under direct observation. The CHWs also monitored patients daily for adverse events. Routine laboratory monitoring–including full blood count, liver function tests, electrolytes, and creatinine–was performed monthly at clinic visits, and a specialist clinician evaluated patients at these visits. Thyroid-stimulating hormone (TSH) was initially measured within the first six months of MDR-TB treatment initiation and subsequently every four to six months. Patients with at least one TSH result elevated above 10.0 mIU/l were initiated on a weight-based dose of levothyroxine, which was continued until one month after completion of MDR-TB therapy; TSH was monitored throughout the treatment period at regular intervals [41]. Patients with a serum potassium value below 3.5 mmol/l received potassium and magnesium supplementation until normalization of serum potassium. Patients experiencing nausea or vomiting were treated with prochlorperazine. Chest radiographs were taken at baseline, every six months, and at treatment completion, and the clinical team attempted to obtain sputum samples for culture of M. tuberculosis at baseline and at each monthly clinic visit.

A community team communicated regularly between the clinics and the community, tracking patients who missed any appointment and assessing the stability of each patient’s household situation. The community team provided patients and their caregivers with counseling about MDR-TB and HIV, food supplements, reimbursement for treatment-related transportation, and other types of psychosocial support as needed. Patients who were clinically unstable or experienced severe adverse events were admitted to Botsabelo Hospital, a specialized MDR-TB inpatient facility in the capital (Maseru).

Data Collection and Analysis

Baseline characteristics, treatment history, and clinical signs and symptoms, including radiographic findings, laboratory values, adverse events, and treatment outcomes, were abstracted from patient records and entered into a Microsoft Access 2003 (Microsoft Corporation, Redmond, WA) database. Standard definitions for retrospective MDR-TB analyses were used to determine final treatment outcomes [42]. Cure was defined as five consecutive negative cultures at least 30 days apart in the final 12 months of treatment, and treatment failure was defined as two or more positive cultures in the final year of treatment or a positive result for any of the final three cultures. Patients were designated treatment completed if they completed treatment according to national protocol but did not meet the definition of cure or treatment failure. Data were analyzed using SAS 9.2 (SAS Institute, Cary, NC).

Results

Nineteen children were included in this analysis (Table 1). At the start of treatment, their ages ranged from two to 15 years old, with a median age of eight years (Table 2). The cohort was characterized by a high prevalence of baseline malnutrition (63%), stunting (63%), HIV co-infection (74%), and severe radiographic findings (cavitary lesions or bilateral disease) (84%). Fifty-three percent of the patients had received two or more previous courses of TB treatment prior to referral. All patients presented with pulmonary manifestations of TB infection, and four patients presented with concurrent extrapulmonary TB (three cases of miliary TB and one case of tuberculous lymphadenitis). Ten patients (53%) were smear-negative at the time of MDR-TB treatment initiation. Figure 1 shows the baseline culture and DST results of the 19 patients.

[Figure omitted. See PDF.]

Table 1. Baseline clinical and demographic characteristics of the first 19 children treated for MDR-TB in Lesotho, 2007–2011.

https://doi.org/10.1371/journal.pone.0037114.t001

[Figure omitted. See PDF.]

Table 2. Baseline characteristics (N = 19).

https://doi.org/10.1371/journal.pone.0037114.t002

[Figure omitted. See PDF.]

Figure 1. Baseline bacteriologic results for pediatric patients treated for MDR-TB.

Note: H: isoniazid; R: rifampicin; DST: drug-susceptibility testing. a One patient (case 19) was culture-negative at baseline but later had DST results, indicating susceptibility to all drugs tested, from a positive culture in the tenth month of treatment.

https://doi.org/10.1371/journal.pone.0037114.g001

Patients were treated with a median of six antituberculous drugs (range, 5 to 9). Sixteen patients (84%) were hospitalized at treatment initiation for a median of 1.5 months (range, 0.5 to 9) (Table 3). Most of these patients did not have a clinical indication for hospitalization at treatment initiation, but were hospitalized because of unstable household situations and other social problems. Among the 18 patients who completed the intensive phase of treatment, the parenteral agent (kanamycin or capreomycin) was administered for a median of nine months (range, 8 to 12).

[Figure omitted. See PDF.]

Table 3. Treatment of MDR-TB and HIV disease.

https://doi.org/10.1371/journal.pone.0037114.t003

Final outcomes were available for 17 patients: 15 patients (88%) had treatment success (seven patients cured and eight patients completed treatment) and two patients (12%) died (Table 3). Both patients who died (case 3 and 16) were co-infected with HIV. These two children showed significant clinical improvement on second-line TB therapy, including substantial weight gain and an end of TB symptoms. During the eighteenth month of treatment, case 3 arrived at the MDR-TB hospital with severe dyspnea and died the next morning of an unknown cause. Case 16 missed her clinic visit in the twelfth month of treatment, and tracking by the community team revealed that the patient had died at home of an unknown cause. No patients defaulted or were lost to follow-up. The two patients currently on treatment have exhibited favorable responses to MDR-TB therapy.

Eighteen patients (95%) experienced at least one adverse event (Table 4). Most adverse events were mild to moderate in severity and were successfully managed without suspending treatment (Table 4). The most common adverse events were hypothyroidism (79%), hypokalemia (68%), and nausea or vomiting (53%). One patient who had been on ART for more than two years experienced elevated liver enzymes two weeks after initiation of MDR-TB treatment (case 9). MDR-TB treatment was suspended until transaminitis resolved, and after five weeks, the MDR-TB regimen was reintroduced without pyrazinamide. In another patient, cycloserine was permanently discontinued due to vision problems (case 8).

[Figure omitted. See PDF.]

Table 4. Frequency of adverse events (N = 19).

https://doi.org/10.1371/journal.pone.0037114.t004

Among the 14 patients with HIV co-infection, the median (interquartile range [IQR]) CD4 cell count at the start of MDR-TB treatment was 486.5 (49.3–714.8) cells/mm3 (Table 3). Eight patients were already on ART at the start of the MDR-TB regimen, and the remaining six patients were started on ART a median of 13.5 days after the MDR-TB regimen. The median (IQR) increase in CD4 cell count during MDR-TB treatment was 397 (276.5–622) cells/mm3, and the median (IQR) weight gain among HIV co-infected patients was 4 (3–6) kg. There were no incidences of immune reconstitution inflammatory syndrome (IRIS) after ART initiation. Three patients were switched from zidovudine to stavudine when they experienced anemia, and one patient was switched from stavudine to zidovudine after the onset of peripheral neuropathy. Another patient who had experienced immunological deterioration prior to MDR-TB treatment was switched from a second-line ART regimen to a first-line regimen when genotypic resistance testing revealed no mutations conferring resistance to first-line antiretroviral drugs.

Discussion

Our results demonstrate that, even in a setting of high HIV prevalence, it is possible to achieve favorable outcomes among children treated for MDR-TB using early empiric treatment delivered through a comprehensive community-based program. The latter included referral to inpatient care as needed. Almost 90% of the children treated experienced cure or treatment completion, despite the geographically challenging setting and the high rate of baseline malnutrition, severe lung damage, and co-infection with HIV. Excluding the four patients who subsequently had DST results suggesting drug-susceptible TB, the mortality rate among confirmed and suspected MDR-TB cases in this study was 13%. Our outcomes were similar to outcomes among children in MDR-TB treatment programs with largely HIV-negative patients, where treatment success rates have ranged from 80 to 100% and crude mortality rates, from 0 to 6% [25]–[28], [32].

In contrast to the favorable outcomes achieved in low HIV prevalence settings, pediatric case series with a high prevalence of HIV have reported lower rates of treatment success [6], [30]. Both of these case series included only culture-confirmed MDR-TB cases, which may imply more extensive diseases at baseline. One study in South Africa reported final outcomes for 31 children treated for confirmed MDR-TB, of whom six were HIV co-infected and 10 were not tested [6]. Twenty-one children (68%) were cured, four (13%) died, and six (19%) defaulted after at least five months of treatment. However, the study was conducted before ART became available in South Africa. Another study from South Africa reported 12-month outcomes for 13 children with MDR-TB, of whom seven were co-infected with HIV and six received ART [30]. In that report, four children died a median of 2.8 months after submitting sputum for culture and DST, including three co-infected children who were unstable at treatment initiation. Of the remaining nine patients, two defaulted, one patient exhibited radiological deterioration, and six showed improvement by 12 months. Delay in the initiation of appropriate treatment likely played a role in the poor outcomes. Patients initiated MDR-TB treatment a median of 2.5 months after submitting sputum, and three of 13 patients died or defaulted before initiating appropriate treatment.

Two recent studies of DR-TB and HIV co-infected children treated concurrently with ART and second-line TB treatment have reported more favorable outcomes [22], [31]. Four pediatric XDR-TB patients with HIV co-infection were successfully cured with co-treatment in South Africa [22]. Another study in South Africa examined outcomes in 111 children with MDR-TB, including 43 children with HIV co-infection, most of whom initiated ART prior to or during MDR-TB treatment. In that report, 82% of patients achieved favorable outcomes, and five of the 13 deaths occurred before confirmation of MDR-TB and initiation of appropriate treatment [31].

In contrast to previous reports on co-infected children, children in the Lesotho program were initiated on empiric second-line TB treatment immediately after evaluation for suspicion of MDR-TB, without waiting for DST confirmation. Treatment delay is particularly problematic among children because of the difficulty in obtaining sputum and the high likelihood of paucibacillary TB. In a study of 39 children with MDR-TB in South Africa, Schaaf et al. found that treatment delay (the time from when MDR-TB should have been clinically suspected until the initiation of treatment) was a median of two days if the DST of the source case was considered and 246 days if the DST of the source case was not considered [6]. For HIV-infected pediatric patients, guidelines recommend prompt initiation of second-line TB treatment using the index case’s DST results if TB disease develops in a child in close contact with an index case with drug-resistant TB [25], [26], [28], [43].

MDR-TB should be suspected when a child has been in contact with a TB patient who died while on treatment and who was suspected to have had MDR-TB [25], [26]. Six children in our case series had household contact with individuals suspected, but not confirmed, of having MDR-TB. The household source cases had either been initiated on empiric MDR-TB treatment as high-risk MDR-TB suspects or had experienced clinical deterioration of their tuberculosis and died while receiving first-line TB treatment. Given the poor outcomes associated with delayed initiation of treatment, our clinicians initiated empiric second-line therapy in these children.

Efforts to obtain sputum samples for culture and DST confirmation for all pediatric patients were aggressive. Clinicians attempted to collect sputum specimens at monthly clinic visits, and gastric lavage and sputum induction were used for young children. For the diagnosis of extrapulmonary MDR-TB, pleural fluid sample and lymph node aspirates are the only non-pulmonary specimens routinely collected and cultured in Lesotho. Compared with adults, children with TB are more likely to have extrapulmonary TB [7], [44]. However, all patients included in this report had pulmonary involvement. As a result of limited diagnostics for the detection of extrapulmonary TB in this setting, those without pulmonary involvement were likely to have been missed. Moreover, an unusually high proportion of patients had bilateral disease or cavitary lesions, which is not associated with the classic pediatric presentations of TB [44], raising the possibility that significant numbers of children with less severe pulmonary disease may have been undetected.

The five patients with culture-confirmed MDR-TB all experienced cure or treatment completion. Of the other 14 patients, six had household contact with a confirmed MDR-TB patient or high-risk MDR-TB suspect, and the remaining patients had failed to respond to at least one previous course of first-line TB treatment. For several patients who initiated an empiric MDR-TB regimen, subsequent DST results indicated susceptibility to isoniazid and rifampicin. However, all had responded well to MDR-TB treatment, experiencing significant clinical and radiological improvement, after having been unsuccessfully treated with at least one first-line TB regimen, so the clinical team decided to continue them on MDR-TB treatment with the addition of rifampicin and high-dose isoniazid. We did not have data on patients’ adherence to previous courses of first-line TB treatment, and it is possible that non-adherence, despite directly observed therapy, may have contributed to failure of first-line treatment. Additionally, three of the four patients had HIV co-infection, making them susceptible to other potential causes of clinical deterioration during first-line TB treatment [45]. Nevertheless, the clinical team decided it was prudent to continue these four patients on a modified version of the second-line regimen to which they had responded clinically.

Although we were striving to provide rapid and appropriate care to these patients, we note that the majority (58%) of the children in our cohort had already received two or more previous regimens of first-line TB drugs, and all but one of the household contacts had been treated previously with first-line drugs, suggesting that there was a delay in recognizing them as MDR-TB suspects and initiating them on appropriate treatment. Additionally, nearly half of the HIV co-infected patients were not receiving ART at the time of MDR-TB treatment initiation, despite the fact that pulmonary TB is a criteria for initiating ART in the clinical staging of HIV/AIDS (irrespective of CD4 cell count) [46]–[48].

Children with HIV co-infection who were not already on ART were initiated on ART as soon as they were tolerating MDR-TB treatment, as early as one week post initiation. Optimal time to introduce ART following the start of TB treatment is uncertain, as early introduction of ART after initiation of TB treatment is believed to be associated with higher risk of IRIS [49], [50]. However, literature on IRIS in adults suggests that mortality from TB-associated IRIS is rare [51], [52], and earlier initiation of ART has been shown to significantly reduce mortality among severely immunosuppressed adults receiving first-line treatment for drug-susceptible TB [53]. The literature on IRIS in children treated for TB is limited to a small number of case reports and case series [54]–[57]. In a study in South Africa, data from 290 children on ART were analyzed for the clinical presentation and outcome of TB [55]. The authors concluded that the poor outcomes among children who started ART within two months of TB treatment was due to the more advanced HIV disease in this group; the early introduction of ART was rarely (<10% of cases) associated with drug-related adverse events or IRIS. In our program in Lesotho, children responded well to concurrent ART and MDR-TB treatment, with few regimen changes required, no defaults, and no episodes of IRIS observed.

In this cohort, children experienced a higher incidence of adverse events compared to other reports [8], [25], [26], [32]. Nearly 80% of patients experienced hypothyroidism a median of 75 days after MDR-TB treatment initiation. Recent studies from South Africa have also reported high rates of abnormal thyroid function tests (>50%) among children treated for MDR-TB [58], [59]. Although hypothyroidism is a known side effect of ethionamide/prothionamide and PAS, recovery from non-thyroidal illness syndrome (NTIS) could also cause a transient TSH elevation in children with TB or HIV infection. However, TSH was elevated >20 mIU/l in eleven patients, and seven patients experienced prolonged TSH elevation lasting more than three months, suggesting primary hypothyroidism rather than recovery from NTIS.

Patients in this study also experienced a high incidence of hypokalemia (68%), which occurred a median of 39 days after the start of the MDR-TB regimen. In adults, electrolyte disturbances, including hypokalemia, have been attributed to the use of aminoglycosides and capreomycin [60], [61]. Low serum potassium may also result from severe malnutrition or diarrhea and vomiting caused by antituberculous agents, such as PAS, or chronic gastrointestinal infections common among HIV patients. Nearly one-third of patients experienced ototoxicity with a median onset of 265 days after initiating MDR-TB treatment. Since audiometry was performed only to confirm patient or caregiver self-report of hearing loss, this likely represents an underestimate, and routine audiometry should be considered for all children receiving treatment for MDR-TB.

Although ART drugs and second-line TB drugs have potential overlapping or additive toxicities [24], it is not clear that HIV co-infection or concurrent ART could explain the higher incidence of adverse events in the cohort, as adverse events were common among both HIV-infected and HIV-uninfected patients. We suspect that the high degree of malnutrition and poor clinical status at baseline may have played a role. Patients were monitored closely at both the community and clinic level, and adverse events were managed aggressively [37], [41], [60].

In addition to close monitoring of the patients’ clinical status, the CHWs and community team provided close monitoring of the patients’ household situation and psychosocial needs. Many patients had been orphaned by HIV and TB (Table 2), and some had been neglected by their caregivers. The community team helped school-aged children to return to school and assisted families without income to start income generating activities. Providing for these psychosocial needs likely helped to achieve zero defaults and favorable treatment outcomes.

The favorable outcomes reported in this study are particularly notable because they were achieved in a predominately ambulatory setting. Because of the complexity of managing MDR-TB and HIV co-infection, the traditional model of MDR-TB treatment in this region of the world has been hospital-based care, and many children with MDR-TB continue to be hospitalized unnecessarily. The community-based treatment model minimized the risk of nosocomial transmission of MDR-TB, which is particularly important in high HIV prevalence settings like Lesotho. Our findings demonstrate that good MDR-TB outcomes in the context of HIV are achievable using a community-based model. However, successful implementation of community-based care in this geographically challenging setting where many patients live in rural, mountainous areas required several key elements, including strong links between the community team and clinicians, well-trained and supervised CHWs, and reimbursement for travel expenses related to treatment [62].

For children suspected of having MDR-TB disease, particularly those with HIV co-infection, empiric second-line TB therapy should be initiated while awaiting DST results. Patients with HIV co-infection not already receiving ART may benefit from early initiation of ART once the MDR-TB treatment regimen is tolerated. Our community-based treatment delivery model included empiric treatment, as well as close monitoring, frequent routine screening, and timely interventions for adverse events. Treatment outcomes for this strategy are comparable to those reported among children with drug-susceptible TB and those without HIV infection.

Acknowledgments

We thank the dedicated clinicians and community health workers at the Lesotho Ministry of Health and Social Welfare and Partners In Health Lesotho.

Author Contributions

Conceived and designed the experiments: HS MMM DBO JSM KJS. Performed the experiments: HS MMM. Analyzed the data: HS MMM SK MCB KJS. Wrote the paper: HS MMM DBO SK MCB JSM KJS.

Citation: Satti H, McLaughlin MM, Omotayo DB, Keshavjee S, Becerra MC, Mukherjee JS, et al. (2012) Outcomes of Comprehensive Care for Children Empirically Treated for Multidrug-Resistant Tuberculosis in a Setting of High HIV Prevalence. PLoS ONE7(5): e37114. https://doi.org/10.1371/journal.pone.0037114

References

1. Keshavjee S, Farmer PE (2010) Picking up the pace–scale-up of MDR tuberculosis treatment programs. N Engl J Med 363: 1781–1784.S. KeshavjeePE Farmer2010Picking up the pace–scale-up of MDR tuberculosis treatment programs.N Engl J Med36317811784

2. Nelson LJ, Wells CD (2004) Global epidemiology of childhood tuberculosis. Int J Tuberc Lung Dis 8: 636–647.LJ NelsonCD Wells2004Global epidemiology of childhood tuberculosis.Int J Tuberc Lung Dis8636647

3. Schaaf HS, Marais BJ, Hesseling AC, Brittle W, Donald PR (2009) Surveillance of antituberculosis drug resistance among children from the Western Cape Province of South Africa–an upward trend. Am J Public Health 99: 1486–1490.HS SchaafBJ MaraisAC HesselingW. BrittlePR Donald2009Surveillance of antituberculosis drug resistance among children from the Western Cape Province of South Africa–an upward trend.Am J Public Health9914861490

4. Schaaf HS, Marais BJ, Hesseling AC, Gie RP, Beyers N, et al. (2006) Childhood drug-resistant tuberculosis in the Western Cape Province of South Africa. Acta Paediatr 95: 523–528.HS SchaafBJ MaraisAC HesselingRP GieN. Beyers2006Childhood drug-resistant tuberculosis in the Western Cape Province of South Africa.Acta Paediatr95523528

5. Schaaf HS, Marais BJ (2011) Management of multidrug-resistant tuberculosis in children: a survival guide for paediatricians. Paediatr Respir Rev 12: 31–38.HS SchaafBJ Marais2011Management of multidrug-resistant tuberculosis in children: a survival guide for paediatricians.Paediatr Respir Rev123138

6. Schaaf HS, Shean K, Donald PR (2003) Culture confirmed multidrug resistant tuberculosis: diagnostic delay, clinical features, and outcome. Arch Dis Child 88: 1106–1111.HS SchaafK. SheanPR Donald2003Culture confirmed multidrug resistant tuberculosis: diagnostic delay, clinical features, and outcome.Arch Dis Child8811061111

7. Graham SM, Gie RP, Schaaf HS, Coulter JB, Espinal MA, et al. (2004) Childhood tuberculosis: clinical research needs. Int J Tuberc Lung Dis 8: 648–657.SM GrahamRP GieHS SchaafJB CoulterMA Espinal2004Childhood tuberculosis: clinical research needs.Int J Tuberc Lung Dis8648657

8. Al-Dabbagh M, Lapphra K, McGloin R, Inrig K, Schaaf HS, et al. (2011) Drug-resistant tuberculosis: pediatric guidelines. Pediatr Infect Dis J 30: 501–505.M. Al-DabbaghK. LapphraR. McGloinK. InrigHS Schaaf2011Drug-resistant tuberculosis: pediatric guidelines.Pediatr Infect Dis J30501505

9. Cruz AT, Starke JR (2007) Clinical manifestations of tuberculosis in children. Paediatr Respir Rev 8: 107–117.AT CruzJR Starke2007Clinical manifestations of tuberculosis in children.Paediatr Respir Rev8107117

10. Eamranond P, Jaramillo E (2001) Tuberculosis in children: reassessing the need for improved diagnosis in global control strategies. Int J Tuberc Lung Dis 5: 594–603.P. EamranondE. Jaramillo2001Tuberculosis in children: reassessing the need for improved diagnosis in global control strategies.Int J Tuberc Lung Dis5594603

11. Steiner P, Rao M, Victoria MS, Hunt J, Steiner M (1983) A continuing study of primary drug-resistant tuberculosis among children observed at the Kings County Hospital Medical Center between the years 1961 and 1980. Am Rev Respir Dis 128: 425–428.P. SteinerM. RaoMS VictoriaJ. HuntM. Steiner1983A continuing study of primary drug-resistant tuberculosis among children observed at the Kings County Hospital Medical Center between the years 1961 and 1980.Am Rev Respir Dis128425428

12. Schaaf HS, Gie RP, Beyers N, Sirgel FA, de Klerk PJ, et al. (2000) Primary drug-resistant tuberculosis in children. Int J Tuberc Lung Dis 4: 1149–1155.HS SchaafRP GieN. BeyersFA SirgelPJ de Klerk2000Primary drug-resistant tuberculosis in children.Int J Tuberc Lung Dis411491155

13. Debre R, Noufflard H, Brissaud HE, Gerbeaux J (1959) Infection of children by strains of tubercle bacilli initially resistant to streptomycin or to isoniazid. Am Rev Respir Dis 80: 326–339.R. DebreH. NoufflardHE BrissaudJ. Gerbeaux1959Infection of children by strains of tubercle bacilli initially resistant to streptomycin or to isoniazid.Am Rev Respir Dis80326339

14. Graham SM (2005) Non-tuberculosis opportunistic infections and other lung diseases in HIV-infected infants and children. Int J Tuberc Lung Dis 9: 592–602.SM Graham2005Non-tuberculosis opportunistic infections and other lung diseases in HIV-infected infants and children.Int J Tuberc Lung Dis9592602

15. Graham SM, Coulter JB, Gilks CF (2001) Pulmonary disease in HIV-infected African children. Int J Tuberc Lung Dis 5: 12–23.SM GrahamJB CoulterCF Gilks2001Pulmonary disease in HIV-infected African children.Int J Tuberc Lung Dis51223

16. Edlin BR, Tokars JI, Grieco MH, Crawford JT, Williams J, et al. (1992) An outbreak of multidrug-resistant tuberculosis among hospitalized patients with the acquired immunodeficiency syndrome. N Engl J Med 326: 1514–1521.BR EdlinJI TokarsMH GriecoJT CrawfordJ. Williams1992An outbreak of multidrug-resistant tuberculosis among hospitalized patients with the acquired immunodeficiency syndrome.N Engl J Med32615141521

17. Frieden TR, Fujiwara PI, Washko RM, Hamburg MA (1995) Tuberculosis in New York City–turning the tide. N Engl J Med 333: 229–233.TR FriedenPI FujiwaraRM WashkoMA Hamburg1995Tuberculosis in New York City–turning the tide.N Engl J Med333229233

18. Frieden TR, Sherman LF, Maw KL, Fujiwara PI, Crawford JT, et al. (1996) A multi-institutional outbreak of highly drug-resistant tuberculosis: epidemiology and clinical outcomes. JAMA 276: 1229–1235.TR FriedenLF ShermanKL MawPI FujiwaraJT Crawford1996A multi-institutional outbreak of highly drug-resistant tuberculosis: epidemiology and clinical outcomes.JAMA27612291235

19. Moro M, Gori A, Errante I, Infuso A, Franzetti F, et al. (1998) An outbreak of multidrug-resistant tuberculosis involving HIV-infected patients of two hospitals in Milan, Italy. Italian Multidrug-Resistant Tuberculosis Outbreak Study Group. AIDS 12: 1095–1102.M. MoroA. GoriI. ErranteA. InfusoF. Franzetti1998An outbreak of multidrug-resistant tuberculosis involving HIV-infected patients of two hospitals in Milan, Italy. Italian Multidrug-Resistant Tuberculosis Outbreak Study Group.AIDS1210951102

20. Fischl M, Uttamchandani R, Daikos G, Poblete R, Moreno J, et al. (1992) An outbreak of tuberculosis caused by multiple-drug-resistant tubercle bacilli among patients with HIV infection. Ann Intern Med 117: 177–183.M. FischlR. UttamchandaniG. DaikosR. PobleteJ. Moreno1992An outbreak of tuberculosis caused by multiple-drug-resistant tubercle bacilli among patients with HIV infection.Ann Intern Med117177183

21. Gandhi NR, Moll A, Sturm AW, Pawinski R, Govender T, et al. (2006) Extensively drug-resistant tuberculosis as a cause of death in patients co-infected with tuberculosis and HIV in a rural area of South Africa. Lancet 368: 1575–1580.NR GandhiA. MollAW SturmR. PawinskiT. Govender2006Extensively drug-resistant tuberculosis as a cause of death in patients co-infected with tuberculosis and HIV in a rural area of South Africa.Lancet36815751580

22. Thomas TA, Shenoi SV, Heysell SK, Eksteen FJ, Sunkari VB, et al. (2010) Extensively drug-resistant tuberculosis in children with human immunodeficiency virus in rural South Africa. Int J Tuberc Lung Dis 14: 1244–1251.TA ThomasSV ShenoiSK HeysellFJ EksteenVB Sunkari2010Extensively drug-resistant tuberculosis in children with human immunodeficiency virus in rural South Africa.Int J Tuberc Lung Dis1412441251

23. WHO/IUATLD (2010) Guidance for national tuberculosis and HIV programmes on the management of tuberculosis in HIV-infected children: Recommendations for a public health approach. Geneva: World Health Organization. WHO/IUATLD2010Guidance for national tuberculosis and HIV programmes on the management of tuberculosis in HIV-infected children: Recommendations for a public health approach.GenevaWorld Health Organization

24. Shenoi S, Heysell S, Moll A, Friedland G (2009) Multidrug-resistant and extensively drug-resistant tuberculosis: consequences for the global HIV community. Curr Opin Infect Dis 22: 11–17.S. ShenoiS. HeysellA. MollG. Friedland2009Multidrug-resistant and extensively drug-resistant tuberculosis: consequences for the global HIV community.Curr Opin Infect Dis221117

25. Drobac PC, Mukherjee JS, Joseph JK, Mitnick C, Furin JJ, et al. (2006) Community-based therapy for children with multidrug-resistant tuberculosis. Pediatrics 117: 2022–2029.PC DrobacJS MukherjeeJK JosephC. MitnickJJ Furin2006Community-based therapy for children with multidrug-resistant tuberculosis.Pediatrics11720222029

26. Mukherjee JS, Joseph JK, Rich ML, Shin SS, Furin JJ, et al. (2003) Clinical and programmatic considerations in the treatment of MDR-TB in children: a series of 16 patients from Lima, Peru. Int J Tuberc Lung Dis 7: 637–644.JS MukherjeeJK JosephML RichSS ShinJJ Furin2003Clinical and programmatic considerations in the treatment of MDR-TB in children: a series of 16 patients from Lima, Peru.Int J Tuberc Lung Dis7637644

27. Feja K, McNelley E, Tran CS, Burzynski J, Saiman L (2008) Management of pediatric multidrug-resistant tuberculosis and latent tuberculosis infections in New York City from 1995 to 2003. Pediatr Infect Dis J 27: 907–912.K. FejaE. McNelleyCS TranJ. BurzynskiL. Saiman2008Management of pediatric multidrug-resistant tuberculosis and latent tuberculosis infections in New York City from 1995 to 2003.Pediatr Infect Dis J27907912

28. Schaaf HS, Gie RP, Kennedy M, Beyers N, Hesseling PB, et al. (2002) Evaluation of young children in contact with adult multidrug-resistant pulmonary tuberculosis: a 30-month follow-up. Pediatrics 109: 765–771.HS SchaafRP GieM. KennedyN. BeyersPB Hesseling2002Evaluation of young children in contact with adult multidrug-resistant pulmonary tuberculosis: a 30-month follow-up.Pediatrics109765771

29. Schluger NW, Lawrence RM, McGuiness G, Park M, Rom WN (1996) Multidrug-resistant tuberculosis in children: two cases and a review of the literature. Pediatr Pulmonol 21: 138–142.NW SchlugerRM LawrenceG. McGuinessM. ParkWN Rom1996Multidrug-resistant tuberculosis in children: two cases and a review of the literature.Pediatr Pulmonol21138142

30. Fairlie L, Beylis NC, Reubenson G, Moore DP, Madhi SA (2011) High prevalence of childhood multi-drug resistant tuberculosis in Johannesburg, South Africa: a cross sectional study. BMC Infect Dis 11: 28.L. FairlieNC BeylisG. ReubensonDP MooreSA Madhi2011High prevalence of childhood multi-drug resistant tuberculosis in Johannesburg, South Africa: a cross sectional study.BMC Infect Dis1128

31. Seddon J, Hesseling A, Willemse M, Donald P, Schaaf H (2012) Culture-Confirmed Multidrug-Resistant Tuberculosis in Children: Clinical Features, Treatment, and Outcome. Clin Infect Dis. pp. 157–166.J. SeddonA. HesselingM. WillemseP. DonaldH. Schaaf2012Culture-Confirmed Multidrug-Resistant Tuberculosis in Children: Clinical Features, Treatment, and Outcome.Clin Infect Dis157166

32. Ettehad D, Schaaf HS, Seddon JA, Cooke GS, Ford N (2012) Treatment outcomes for children with multidrug-resistant tuberculosis: a systematic review and meta-analysis. Lancet Infect Dis. D. EttehadHS SchaafJA SeddonGS CookeN. Ford2012Treatment outcomes for children with multidrug-resistant tuberculosis: a systematic review and meta-analysis.Lancet Infect Dis

33. Ministry of Health and Social Welfare (2009) Ministry of Health and Social Welfare2009Demographic and Health Survey, Lesotho: Ministry of Health and Social Welfare, Bureau of Statistics. Available: www.measuredhs.com/pubs/pdf/FR241/FR241.pdf. Accessed 14 Mar 2012. Demographic and Health Survey, Lesotho: Ministry of Health and Social Welfare, Bureau of Statistics. Available: www.measuredhs.com/pubs/pdf/FR241/FR241.pdf. Accessed 14 Mar 2012.

34. World Health Organization (2011) World Health Organization2011TB data: Tuberculosis country profiles. Available: http://www.who.int/tb/country/en/index.html. Accessed 1 Nov 2011. TB data: Tuberculosis country profiles. Available: http://www.who.int/tb/country/en/index.html. Accessed 1 Nov 2011.

35. Partners In Health (2011) Partners In Health 2011 Annual Report: From Innovation to Transformation. Boston, MA: Partners In Health. Partners In Health2011Partners In Health 2011 Annual Report: From Innovation to Transformation.Boston, MAPartners In Health

36. Mukherjee JS, Rich ML, Socci AR, Joseph JK, Viru FA, et al. (2004) Programmes and principles in treatment of multidrug-resistant tuberculosis. Lancet 363: 474–481.JS MukherjeeML RichAR SocciJK JosephFA Viru2004Programmes and principles in treatment of multidrug-resistant tuberculosis.Lancet363474481

37. World Health Organization (2008) Guidelines for the programmatic management of drug-resistant tuberculosis: Emergency update 2008. Geneva: WHO. World Health Organization2008Guidelines for the programmatic management of drug-resistant tuberculosis: Emergency update 2008.GenevaWHO

38. World Health Organization (2011) Guidelines for the programmatic management of drug-resistant tuberculosis: 2011 update. Geneva: WHO. World Health Organization2011Guidelines for the programmatic management of drug-resistant tuberculosis: 2011 update.GenevaWHO

39. Seung KJ, Omatayo DB, Keshavjee S, Furin JJ, Farmer PE, et al. (2009) Early outcomes of MDR-TB treatment in a high HIV-prevalence setting in southern Africa. PLoS ONE 4: e7186.KJ SeungDB OmatayoS. KeshavjeeJJ FurinPE Farmer2009Early outcomes of MDR-TB treatment in a high HIV-prevalence setting in southern Africa.PLoS ONE4e7186

40. Cilliers K, Labadarios D, Schaaf HS, Willemse M, Maritz JS, et al. (2010) Pyridoxal-5-phosphate plasma concentrations in children receiving tuberculosis chemotherapy including isoniazid. Acta Paediatr 99: 705–710.K. CilliersD. LabadariosHS SchaafM. WillemseJS Maritz2010Pyridoxal-5-phosphate plasma concentrations in children receiving tuberculosis chemotherapy including isoniazid.Acta Paediatr99705710

41. Satti H, Mafukidze A, Jooste PL, McLaughlin MM, Farmer PE, et al. (2012) High rate of hypothyroidism among patients treated for MDR-TB in Lesotho. Int J Tuberc Lung Dis 16: 468–472.H. SattiA. MafukidzePL JoosteMM McLaughlinPE Farmer2012High rate of hypothyroidism among patients treated for MDR-TB in Lesotho.Int J Tuberc Lung Dis16468472

42. Laserson KF, Thorpe LE, Leimane V, Weyer K, Mitnick CD, et al. (2005) Speaking the same language: treatment outcome definitions for multidrug-resistant tuberculosis. Int J Tuberc Lung Dis 9: 640–645.KF LasersonLE ThorpeV. LeimaneK. WeyerCD Mitnick2005Speaking the same language: treatment outcome definitions for multidrug-resistant tuberculosis.Int J Tuberc Lung Dis9640645

43. Tuberculosis Coalition for Technical Assistance (2006) Assistance Tuberculosis Coalition for Technical2006International Standards for Tuberculosis Care (ISTC). The Hague: Tuberculosis Coalition for Technical Assistance. Available: http://www.istcweb.org/documents/istcenglish.pdf. Accessed 14 Mar 2012. International Standards for Tuberculosis Care (ISTC). The Hague: Tuberculosis Coalition for Technical Assistance. Available: http://www.istcweb.org/documents/istcenglish.pdf. Accessed 14 Mar 2012.

44. Donald PR, Marais BJ, Barry CE, 3rd (2010) Age and the epidemiology and pathogenesis of tuberculosis. Lancet 375: 1852–1854.PR DonaldBJ MaraisCE Barry3rd2010Age and the epidemiology and pathogenesis of tuberculosis.Lancet37518521854

45. Pepper DJ, Marais S, Wilkinson RJ, Bhaijee F, Maartens G, et al. (2010) Clinical deterioration during antituberculosis treatment in Africa: incidence, causes and risk factors. BMC Infect Dis 10: 83.DJ PepperS. MaraisRJ WilkinsonF. BhaijeeG. Maartens2010Clinical deterioration during antituberculosis treatment in Africa: incidence, causes and risk factors.BMC Infect Dis1083

46. Centers for Disease Control and Prevention (1992) 1993 Revised Classification System for HIV Infection and Expanded Surveillance Case Definition for AIDS Among Adolescents and Adults Morbidity and Mortality Weekly Report 41: 961–962.Centers for Disease Control and Prevention19921993 Revised Classification System for HIV Infection and Expanded Surveillance Case Definition for AIDS Among Adolescents and Adults Morbidity and Mortality Weekly Report41961962

47. Centers for Disease Control and Prevention (1998) Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection Morbidity and Mortality Weekly Report 47: 1–31.Centers for Disease Control and Prevention1998Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection Morbidity and Mortality Weekly Report47131

48. World Health Organization (2010) Antiretroviral therapy for HIV infection in adults and adolescents: Recommendations for a public health approach: 2010 revision. Geneva: WHO. World Health Organization2010Antiretroviral therapy for HIV infection in adults and adolescents: Recommendations for a public health approach: 2010 revision.GenevaWHO

49. Lawn SD, Myer L, Bekker LG, Wood R (2007) Tuberculosis-associated immune reconstitution disease: incidence, risk factors and impact in an antiretroviral treatment service in South Africa. AIDS 21: 335–341.SD LawnL. MyerLG BekkerR. Wood2007Tuberculosis-associated immune reconstitution disease: incidence, risk factors and impact in an antiretroviral treatment service in South Africa.AIDS21335341

50. Meintjes G, Lawn S, Scano F, Maartens G, French M, et al. (2008) Tuberculosis-associated immune reconstitution inflammatory syndrome: case definitions for use in resource-limited settings. Lancet Infect Dis 8: 516–523.G. MeintjesS. LawnF. ScanoG. MaartensM. French2008Tuberculosis-associated immune reconstitution inflammatory syndrome: case definitions for use in resource-limited settings.Lancet Infect Dis8516523

51. Muller M, Wandel S, Colebunders R, Attia S, Furrer H, et al. (2010) Immune reconstitution inflammatory syndrome in patients starting antiretroviral therapy for HIV infection: a systematic review and meta-analysis. Lancet Infect Dis 10: 251–261.M. MullerS. WandelR. ColebundersS. AttiaH. Furrer2010Immune reconstitution inflammatory syndrome in patients starting antiretroviral therapy for HIV infection: a systematic review and meta-analysis.Lancet Infect Dis10251261

52. Lawn SD, Bekker LG, Miller RF (2005) Immune reconstitution disease associated with mycobacterial infections in HIV-infected individuals receiving antiretrovirals. Lancet Infect Dis 5: 361–373.SD LawnLG BekkerRF Miller2005Immune reconstitution disease associated with mycobacterial infections in HIV-infected individuals receiving antiretrovirals.Lancet Infect Dis5361373

53. Blanc F, Sok T, Laureillard D (2010) Significant enhancement in survival with early (2 weeks) vs. late (8 weeks) initiation of highly active antiretroviral treatment (HAART) in severely immunosuppressed HIV-infected adults with newly diagnosed tuberculosis. XVIII International AIDS Conference. Vienna. F. BlancT. SokD. Laureillard2010Significant enhancement in survival with early (2 weeks) vs.late (8 weeks) initiation of highly active antiretroviral treatment (HAART) in severely immunosuppressed HIV-infected adults with newly diagnosed tuberculosis. XVIII International AIDS Conference. Vienna

54. Zampoli M, Kilborn T, Eley B (2007) Tuberculosis during early antiretroviral-induced immune reconstitution in HIV-infected children. Int J Tuberc Lung Dis 11: 417–423.M. ZampoliT. KilbornB. Eley2007Tuberculosis during early antiretroviral-induced immune reconstitution in HIV-infected children.Int J Tuberc Lung Dis11417423

55. Walters E, Cotton MF, Rabie H, Schaaf HS, Walters LO, et al. (2008) Clinical presentation and outcome of tuberculosis in human immunodeficiency virus infected children on anti-retroviral therapy. BMC Pediatr 8: 1.E. WaltersMF CottonH. RabieHS SchaafLO Walters2008Clinical presentation and outcome of tuberculosis in human immunodeficiency virus infected children on anti-retroviral therapy.BMC Pediatr81

56. Boulware DR, Callens S, Pahwa S (2008) Pediatric HIV immune reconstitution inflammatory syndrome. Curr Opin HIV AIDS 3: 461–467.DR BoulwareS. CallensS. Pahwa2008Pediatric HIV immune reconstitution inflammatory syndrome.Curr Opin HIV AIDS3461467

57. Puthanakit T, Oberdorfer P, Akarathum N, Wannarit P, Sirisanthana T, et al. (2006) Immune reconstitution syndrome after highly active antiretroviral therapy in human immunodeficiency virus-infected thai children. Pediatr Infect Dis J 25: 53–58.T. PuthanakitP. OberdorferN. AkarathumP. WannaritT. Sirisanthana2006Immune reconstitution syndrome after highly active antiretroviral therapy in human immunodeficiency virus-infected thai children.Pediatr Infect Dis J255358

58. Thee S, Zollner EW, Willemse M, Hesseling AC, Magdorf K, et al. (2011) Abnormal thyroid function tests in children on ethionamide treatment. Int J Tuberc Lung Dis 15: 1191–1193, i: S. TheeEW ZollnerM. WillemseAC HesselingK. Magdorf2011Abnormal thyroid function tests in children on ethionamide treatment.Int J Tuberc Lung Dis 15: 1191–1193,i

59. Hallbauer UM, Schaaf HS (2011) Ethionamide-induced hypothyroidism in children. South Afr J Epidemiol Infect 26: 161–163.UM HallbauerHS Schaaf2011Ethionamide-induced hypothyroidism in children.South Afr J Epidemiol Infect26161163

60. Shin S, Furin J, Alcantara F, Hyson A, Joseph K, et al. (2004) Hypokalemia among patients receiving treatment for multidrug-resistant tuberculosis. Chest 125: 974–980.S. ShinJ. FurinF. AlcantaraA. HysonK. Joseph2004Hypokalemia among patients receiving treatment for multidrug-resistant tuberculosis.Chest125974980

61. Dheda K, Shean K, Zumla A, Badri M, Streicher EM, et al. (2010) Early treatment outcomes and HIV status of patients with extensively drug-resistant tuberculosis in South Africa: a retrospective cohort study. Lancet 375: 1798–1807.K. DhedaK. SheanA. ZumlaM. BadriEM Streicher2010Early treatment outcomes and HIV status of patients with extensively drug-resistant tuberculosis in South Africa: a retrospective cohort study.Lancet37517981807

62. USAID TB Care II (2011) Community-based care for drug-resistant tuberculosis: a guide for implementers. II USAID TB Care2011Community-based care for drug-resistant tuberculosis: a guide for implementers

63. Centers for Disease Control and Prevention (2002) Vital and Health Statistics Series 11, Number 246: 2000 CDC Growth Charts for the United States: Methods and Development. Hyattsville, MD: Department of Health and Human Serivces. Centers for Disease Control and Prevention2002Vital and Health Statistics Series 11, Number 246: 2000 CDC Growth Charts for the United States: Methods and Development.Hyattsville, MDDepartment of Health and Human Serivces