Acquired Immune Deficiency Syndrome (AIDS) is a disease in which the human immunodeficiency virus (HIV) enters the body and destroys T-lymphocytes, mainly helper T-lymphocytes, leaving the patient’s immune system severely compromised and prone to conditionally pathogenic infections and, rarely, malignant tumors that can cause death. This can lead to death.
However, the detection of HIV in the blood only indicates that the patient is infected with HIV. Some people (60% ~ 70%) are infected with HIV, initially asymptomatic, (asymptomatic carriers); about 25% ~ 30%, within 3-5 years, show AIDS-relatedcomplex (ARC), about 10% ~ 25% then develop typical AIDS. Generally, within 10 years (up to 15 years), 50-75% will develop AIDS. It is clear from this that most people infected with HIV do not develop the disease in the early stages and are simply carriers of the virus.
Tuberculosis is the most common opportunistic infection in people with AIDS. Among HIV patients with TB, 70% have extrapulmonary TB and 30% have pulmonary TB. As with tuberculosis, most TB patients with comorbid AIDS can be cured with anti-TB treatment, while a small number require surgery, such as tuberculous abscess chest, spinal TB, lymphatic TB, and intestinal TB combined with intestinal obstruction. Although there is a lot of literature reporting surgery in AIDS patients, the literature on surgery in TB combined with AIDS is rare. This may be related to many factors, such as mastery of surgical indications and lack of surgical experience.
I. Indications for surgery and timing of surgery in TB combined with AIDS: It should be noted that in patients with TB combined with AIDS who require surgery, not only the indications for surgery in TB but also the factors of AIDS should be taken into account. Seventy percent of tuberculosis combined with AIDS is extrapulmonary tuberculosis. The indications for surgery for extrapulmonary tuberculosis are not exhaustive internationally or domestically, and the indications for surgery vary from site to site and from sign to sign. The clear indications are tuberculous abscess chest, pneumothorax, spinal tuberculosis with paraplegia or significant neurological compression or the presence of large dead bone or abscess, total joint tuberculosis, self-excised kidney, lymphatic tuberculosis with a diameter of more than 3CM, intestinal tuberculosis with acute intestinal obstruction or intestinal fistula, and pneumothorax. However, in the case of combined AIDS, the indications for surgery for TB will change and the indications may be narrower because more patients or the patient’s family will choose conservative treatment as long as those TB lesions that cause physical pain to the patient such as affecting walking, pain, fever, chest tightness, etc. will make the patient actively choose surgery. All 30 patients in this group had extrapulmonary tuberculosis with sites including chest, lung, bone, kidney, lymph, liver, intestinal canal, etc. Tuberculosis lesions in these sites were not effective with drugs alone, and at the same time caused pain and inconvenience to the patient’s body and life, and most patients were willing to undergo surgery. In five cases, the tuberculous lesions were found during lymph node biopsy.
Second, the surgical indications and timing of surgery for combined tuberculosis with AIDS: The timing of surgery should take the AIDS factor into consideration. The CD4+ T lymphocyte count is the main indicator to assess the immune function, and surgery in HIV/AIDS patients should be performed according to the absolute CD4+ count, which is the clearest indicator of the damage status of the immune system in HIV-infected patients. elevated, increasing the risk of surgery, and the rate of postoperative incisional infections is also much higher in HIV/AIDS patients than in normal subjects. In general, if the CD4+ T lymphocyte count is normal, the nutritional status is fair, and there are no complications, they can tolerate various major surgical blows and be prepared for surgical treatment as normal. For patients with CD4+ T lymphocyte count (200-400) /μL, if they are still in good health, they can also tolerate medium to large scale surgery. If surgery is the only way to save the patient’s life, the patient’s CD4+ T-lymphocyte count may be disregarded and surgery should be performed as soon as possible.
However, the results of this group do not seem to support these conclusions. The CD4+ T lymphocyte count in this group was <200 cells/μL in 17 cases and <50 cells/μ in 3 cases, and none of them had incisional infection or delayed healing complications. 2 cases of delayed incisional healing may be related to incomplete intraoperative TB lesion removal. The cause of death was electrolyte disturbance and nutritional imbalance. Although the preoperative CD4+ was only 6/μ, the cause of death was not causally related to AIDS, but was closely related to intestinal obstruction. This suggests that CD4+ T lymphocyte count is not the only criterion to determine the timing of surgery for TB combined with AIDS. Except for patients undergoing emergency surgery, among the 10 patients with tuberculosis combined with AIDS who underwent elective surgery, those with CD4+ count >200/μ had good spirit, sleep, skin color, and diet, and these patients recovered quickly after surgery, indicating that the incisional infection and other complications were low when the operation was performed with CD4+ count >200/μ, but conversely, if the operation was performed with CD4+ count <200 However, on the contrary, if the CD4+ count is <200/μ, the incisional infection and other complications may not be high. This may be related to the characteristics of tuberculosis itself, the timing of surgery, and the choice of surgical approach. However, for TB, which is a chronic disease, there are very few patients with acute surgery, data are not easy to collect, and there are few clinical cases, so how high and how severe the complication rate is when performed with very low CD4+ counts still needs to be further studied with a large specimen size. Preoperative hematocrit and C-reactive protein also have an impact on the timing of surgery. The choice of surgical approach for the surgical treatment of tuberculosis with AIDS is quite important. Different surgical approaches are available for different lesion characteristics, and improper choice of surgical approach is obviously associated with postoperative complications. The duration of preoperative anti-TB, the presence or absence of TB toxicity symptoms in the patient, and clinical experience influence the incidence of postoperative complications in TB. We observed a significantly higher incidence of postoperative complications among non-tuberculous surgeons than among tuberculous surgeons. The tuberculous septic chest in our group was the first case of septic chest surgery with combined AIDS performed by the authors. Should the surgical approach in combined AIDS be the same as in tuberculosis? Or what exactly is the patient’s problem to be addressed? Whether the surgery should be large or small should be carefully considered before surgery. Also, is internal fixation necessary in cases of spinal tuberculosis combined with AIDS? There is not much information on the patient and no conclusions can be drawn yet. In conclusion, surgery is possible when TB is combined with AIDS, but the factors of AIDS should be fully taken into account, and the indications for surgery, the timing of surgery, and the surgical method should be carefully chosen to minimize the risk of surgery.