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OJHAS: Vol. 3, Issue
3: (2004 Jul-Sep) |
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| Comparative Study of HIV Associated Pulmonary
Tuberculosis in Chest Clinics from Two Regions of Edo State, Nigeria |
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Nwobu GO
Department of Medical
Laboratory Sciences, Ambrose Alli University, PMB 14, Ekpoma, Nigeria
Okodua MA
University Health Services,
Ambrose Alli University, PMB 14, Ekpoma, Nigeria
Tatfeng YM
Department of Medical
Microbiology, Ambrose Alli University, PMB 14, Ekpoma, Nigeria
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Address For Correspondence |
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Okodua MA,
University Health Services,
Ambrose Alli University,
PMB 14, Ekpoma, Nigeria
E-mail: marcel_okodua@yahoo.co.uk
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| Nwobu GO, Okodua MA,
Tatfeng YM. Comparative Study Of HIV Associated Pulmonary Tuberculosis In Chest Clinics
From Two Regions Of Edo State, Nigeria
Online J Health Allied Scs.2004;3:4 |
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Submitted: Feb 19,
2004; Revised: Sep 27, 2004; Accepted: Sep 30, 2004; Published:
Oct 18,
2004 |
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| Abstract: |
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A comparative study of HIV associated pulmonary tuberculosis (HIV-PTB) was carried out in
Chest Clinics situated in Benin and Irrua environs of Edo State, Nigeria, using
microscopical and serological methods. In Irrua environs, HIV-PTB co-infection is higher
in females (12.5%) than in males (9.2%) but not statistically significant (P > 0.05).
In Benin, HIV-PTB is also higher in females (11.3%) than in males (7.2%) but not
statistically significant (P > 0.05). In Benin, PTB is statistically high among <20
years and 21–30 years old subjects (50% and 28.7% respectively, P < 0.05), while
HIV is statistically high among age group 31–40 years and 41.50 years (23.5% and
27.9% respectively, P < 0.05). HIV-PTB co-infection is also statistically high among
drivers and traders (13.8% and 12.6% respectively, P < 0.05) in Benin. Generally, there
is no significant difference in the prevalence of HIV, PTB and HIV-PTB infection rate in
the two regions when sex and occupation of the subjects are considered (P > 0.05).
However, subjects of > 60 years old have a significantly higher PTB disease in
Benin than their counterpart in Irrua (28.6% and 0% respectively, P < 0.05).
Key Words:
HIV, Pulmonary Tuberculosis, Edo State
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The association
between HIV and tuberculosis present an immediate and grave public health and
socio-economic threat in developing countries.1 Persons infected by tubercle
bacilli have about a 10% chance of developing tuberculosis during the remainder of their
lives: thus, they have a less than 0.5% chance of developing overt disease annually2,
while 10% of persons infected by both TB and HIV develop tuberculosis disease annually.3
The implication of HIV infection is that it activates dormant tuberculosis to rapid
disease progression of tuberculosis and death.4 In fact, tuberculosis is now
the most common opportunistic infection in Africa patients who die from AIDS.5
Reports show that active tuberculosis increases the morbidity and fatality of HIV infected
person, and about one- third die of tuberculosis.3
Despite the fact
that patients with HIV-related tuberculosis often respond to standard short course
chemotherapy, those in Africa are almost 4 times as likely to die of tuberculosis than
HIV-negative patients within 13 months of diagnosis, mostly in the first month of therapy.6
Even if therapy induces a bacteriological cure, the life span of the patient is still
shortened for reasons not yet known.2 However, there is evidence that immune
responses in tuberculosis and in other infection induce cytokines that enhance the
replication of HIV and this drives the patient into full picture of AIDS.7
There is also evidence that TNF-a and other immunological mediators released in
tuberculosis lead to transactivation of the HIV provirus and its subsequent replication.8
Furthermore, tuberculosis causes decrease in number of CD4 T-lymphocyte9,
which may synergies with that induced by HIV.
In 1992, WHO estimated
that about 4 million people have been infected with both M. tuberculosis and HIV
since the beginning of the pandemic, with 95% being in developing countries.10
The largest increase in tuberculosis has occurred in locations and demographic groups with
the highest HIV prevalence, which suggests that the epidemic of HIV is at least partially
responsible for the increase of tuberculosis.11
Sample Population
And Selection
Patients clinically suspected of having pulmonary tuberculosis (PTB) were used in this
study, and systematic sampling method12 was used by selecting every third
patients visiting the clinic for the first time. Finally, 102 patients (54 males and 48
females) from Irrua environs and 303 patients (153 males and 150 females) from Benin
environs had their sputum and blood samples collected for analysis.
Sample Collection
Three sputum specimens were collected from each subject. These were ‘first spot’
specimen, an early morning specimen and a ‘second spot’ specimen.10
The selected subjects were given two dry, clean, universal containers each. They were
instructed to produce sputum from a deep cough into one of the containers on the first day
they visited the clinic (first spot specimen), and thereafter 2ml of venous blood was
collected from each patient that same day into a clean, dry test tube. The subjects took
the second universal container home and they were instructed to produce an early morning
sputum from a deep cough (early morning specimen). On arrival to the laboratory with the
early morning specimen, another sputum specimen (second spot specimen) was collected from
each subject. The samples were taken to the laboratory for analysis.
Sample Analysis
All the sputum specimens were analysed in a safety cabinet for the presence of acid fast
bacilli (AFB) using the Ziehl-Neelsen method.13
The blood specimens
were screened for the presence of HIV using WHO strategy-two of HIV antibody screening14,
by using the latex aggregation method (Capillus HIV-1/ HIV-2) as described by Cambridge
Diagnostic; and the indirect solid phase enzyme immunoassay (EIA) method (Immunocomb HIV-1
and HIV-2) as described by Orgenics.
Data Analysis
The data generated was analyzed statistically, and the chi-square test was used to
ascertain the influence of sex, age, occupation and environment on the prevalence of HIV,
PTB, and HIV related tuberculosis.
Three reference
centers used in this study are Irrua Specialist Hospital, Irrua; University of Benin
Teaching Hospital, Benin and Central Hospital, Benin.
In Irrua, 102 subjects
(54 males and 48 females) were examined, 13 (12.7%) were found to be infected with HIV; 16
(15.7%) had PTB, while 11 (10.8%) had HIV and PTB (HIV-PTB) and 62 (60.8%) were neither
infected with HIV nor PTB (Non HIV/Non PTB). HIV infection is higher in females 9 (18.8%)
than males 4 (7.4%), difference not statistically significant (P >0.05). Similarly,
HIV-PTB is also higher in females (6 patients, 12.5%) than males (5 patients, 9.2%) but
not statistically significant (P >0.05). PTB is found to be higher in males (11
patients, 20.4%) than females (5 patients,10.4%) but not statistically significant (P >
0.05). (See Table 1)
Table 1: Distribution
of HIV and PTB by sex of subjects in Irrua
Subjects |
Number Examined |
Number Positive |
HIV alone (%) |
PTB alone (%) |
HIV-PTB (%) |
Non HIV/Non PTB |
Male |
54 |
4 (7.4) |
11 (20.4) |
5 (9.2) |
34 (63.0) |
Female |
48 |
9 (18.8) |
5 (10.4) |
6 (12.5) |
28 (58.3) |
Total |
102 |
13 (12.7) |
16 (15.7) |
11 (10.8) |
62 (60.8) |
Key: HIV: Human Immunodeficiency
Virus; PTB: Pulmonary tuberculosis; HIV-PTB: HIV related pulmonary tuberculosis
In Benin City and its environs, 303 subjects (153 males and 150
females) were examined, 55 (18.2%) had HIV, 72 (23.8%) had PTB, 28 (9.2%) had HIV-PTB,
while 148 (48.8%) had neither HIV nor PTB. HIV in females (35 patients, 23.3%) is
statistically higher than in males (20 patients, 13.1%) (P < 0.05). Although, HIV-PTB
co-infection in females (17 patients, 11.3%) is also higher than males (11 patients,
7.2%), and PTB is higher in males (43 patients, 28.1%) than females (29 patients, 19.3%),
they are not statistically significant (P >0.05%). (See Table 2)
Table 2: Distribution of HIV and PTB by sex of subjects in Benin
City
Subjects |
Number examined |
Number Positive |
HIV alone (%) |
PTB alone (%) |
HIV-PTB (%) |
Non HIV/Non PTB (%) |
Male |
153 |
20 (13.1) |
43 (28.1) |
11 ((7.2) |
79 (51.6) |
Female |
150 |
35 (23.2) |
29 (19.3) |
17 (11.3) |
69 (46) |
Total |
303 |
55 (18.2) |
72 (23.8) |
28 (9.2) |
148 (48.8) |
In Irrua, HIV infection
is relatively higher among subjects of age groups 30–40 years (22.5%) and 41–50
years (14.3%) but the difference not statistically significant (P >0.05, Table 3). PTB
is however statistically higher in subjects of age group 21–30 years (40%, P
<0.05, Table 3). Although HIV-PTB co-infection among the various age groups range
between 0% to 19%, their differences are not statistically significant (P >0.05, Table
3).
Table 3: Distribution of HIV and PTB by age groups of subjects in Irrua
Age range (yrs) |
n |
Number (%) of patients positive |
HIV alone (%) |
PTB alone (%) |
HIV-PTB (%) |
Non HIV/Non PTB (%) |
M |
F |
T |
M |
F |
T |
M |
F |
T |
M |
F |
T |
£20 |
2 |
0 (0) |
0 (0) |
0 (0) |
1 (50) |
0 (0) |
1 (50) |
0 (0) |
0 (0) |
0 (0) |
0 (0) |
1 (50) |
1 (50) |
21-30 |
15 |
0 (0) |
1 (6.7) |
1 (6.7) |
4 (26.7) |
2 (13.3) |
6 (40) |
0 (0) |
1 (6.7) |
1 (6.7) |
3 (20) |
4 (26.7) |
7 (46.7) |
31-40 |
40 |
3 (7.5) |
6 (15) |
9 (22.5) |
5 (12.5) |
1 (2.5) |
6 (15) |
2 (5) |
2 (5) |
4 (10) |
11 (27.5) |
10 (25) |
21 (52.5) |
41-50 |
21 |
1 (4.8) |
2 (9.5) |
3 (14.3) |
1 (4.8) |
2 (9.5) |
3 (14.3) |
2 (9.5) |
2 (9.5) |
4 (19) |
8 (38.1 |
3 (14.3) |
11 (52.3) |
51-60 |
13 |
0 (0) |
0 (0) |
0 (0) |
0 (0) |
0 (0) |
0 (0) |
0 (0) |
1 (7.7) |
1 (7.7) |
6 (46.1) |
6 (46.1) |
12 (92.3) |
>60 |
11 |
0 (0) |
0 (0) |
0 (0) |
0 (0) |
0 (0) |
0 (0) |
1 (9.1) |
0 (0) |
1 (9.1) |
6 (54.5) |
4 (36.4) |
10 (90.9) |
Total |
102 |
4(3.9) |
9(8.8) |
13(12.7) |
11(10.8) |
5(4.9) |
16(15.7) |
5(4.9) |
6(5.9) |
11(10.8) |
34(33.3) |
28(27.5) |
62(60.8) |
Key: n = number of subjects
examined; M = males; F = Females; T = Total
Table 4 shows the distribution of HIV and PTB by the age groups of the
subjects in Benin and its environs. HIV infection is statistically higher among age groups
31–40 years (25.3%) and 41–50 years (27.9%, P < 0.05), while PTB is
statistically higher among age groups <20 years (50%) and 21–30 years
(28.7%, P < 0.05). However, the distribution of HIV-PTB co-infection among the various
age groups is not statistically significant (P > 0.05).
Table 4: Distribution of HIV and PTB by age groups of subjects in
Benin City
Age range (yrs) |
n |
Number (%) of patients positive |
HIV alone (%) |
PTB alone (%) |
HIV-PTB (%) |
Non HIV/Non PTB (%) |
M |
F |
T |
M |
F |
T |
M |
F |
T |
M |
F |
T |
£ 20 |
22 |
0 (0) |
0 (0) |
0 (0) |
4 (18.2) |
7 (31.8) |
11 (50) |
0 (0) |
0 (0) |
0 (0) |
7 (31.8) |
4 (31.8) |
11 (50) |
21-30 |
94 |
2 (2.1) |
13 (13.8) |
15 (16) |
17 (18.1) |
10 (10.6) |
27 (28.7) |
2 (2.1) |
6 (6.4) |
8 (8.5) |
23 (24.5) |
21 (22.3) |
44 (46.8) |
31-40 |
87 |
9 (10.3) |
13 (14.9) |
22 (25.3) |
13 (14.9) |
7 (8) |
20 (23) |
6 (6.9) |
6 (6.9) |
12 (13.8) |
21 (24.1) |
12 (13.8) |
33 (37.9) |
41-50 |
61 |
8 (13.1) |
9 (14.8) |
17 (27.9) |
6 (9.8) |
3 (4.9) |
9 (14.8) |
2 (3.3) |
3 (4.9) |
5 (8.2) |
16 (26.2) |
14 (23) |
30 (49.2) |
51-60 |
25 |
1 (4) |
0 (0) |
1 (4) |
0 (0) |
1 (4) |
1 (4) |
1 (4) |
1 (4) |
2 (8) |
9 (36) |
12 (49) |
21 (84) |
>60 |
14 |
0 (0) |
0 (0) |
0 (0) |
3 (21.4) |
1 (7.1) |
4 (28.6) |
0 (0) |
1 (7.1) |
1 (7.1) |
3 (21.4) |
6 (42.9) |
9 (64.3) |
Total |
303 |
20 (6.6) |
35 (11.6) |
55 (18.2) |
43 (14.2) |
29 (9.6) |
72 (23.8) |
11 (3.6) |
17 (5.6) |
28 (9.2) |
79 (26.1) |
69 (22.8) |
148 (48.8) |
Table 5 shows the
distribution of HIV and PTB among the subjects according to their occupation. In Irrua
(Table 5), HIV infection is more in drivers (22.2%) and traders (20.4%), PTB is more in
drivers (22.2%) and students (40%), while HIV-PTB co-infection is more among drivers
(22.2%). However these differences in the infection rate among the various occupations are
not statistically significant (P >0.05).
Table 5: Distribution of HIV and PTB by occupation of subjects in
Irrua.
Occupation |
n |
Number (%) of patients positive |
HIV alone (%) |
PTB alone (%) |
HIV-PTB(%) |
Non HIV/Non PTB (%) |
M |
F |
T |
M |
F |
T |
M |
F |
T |
M |
F |
T |
CS |
9 |
0 (0) |
0 (0) |
0 (0) |
1 (11.1) |
0 (0) |
1 (11.1) |
0 (0) |
0 (0) |
0 (0) |
5 (55.6) |
3 (33.3) |
8 (88.9) |
DR |
9 |
2 (22.2) |
0 (0) |
2 (22.2) |
2 (22.2) |
0 (0) |
2 (22.2) |
2 (22.2) |
0 (0) |
2 (22.2) |
3 (33.3) |
0 (0) |
3 (33.3) |
FM |
20 |
0 (0) |
0 (0) |
0 (0) |
2 (10) |
0 (0) |
2 (10) |
1 (5) |
0 (0) |
1 (5) |
17 (85) |
0 (0) |
17 (85) |
ST |
15 |
0 (0) |
1 (6.7) |
1 (6.7) |
5 (33.3) |
1 (6.7) |
6 (40) |
1 (6.7) |
0 (0) |
1 (6.7) |
3 (20) |
4 (26.7) |
7 (46.7) |
TR |
49 |
2 (4.1) |
8 (16.3) |
10 (20.4) |
1 (2) |
4 (8.2) |
5 (10.2) |
1 (2) |
6 (12.2) |
7 (14.3) |
6 (12.2) |
21 (42.9) |
27 (55.1) |
Total |
102 |
4 (3.9) |
9 (8.8) |
13 (12.7) |
11 (10.8) |
5 (4.9) |
16 (15.7) |
5 (4.9) |
6 (5.9) |
11 (10.8) |
34 (33.3) |
28 (27.5) |
62 (60.8) |
Key: n = number of subjects
examined; M = males; F = Females; T = Total; CS = Civil servants; DR = Drivers; FM =
Farmers; ST = students; TR = Traders
Table 6 shows the distribution of HIV and PTB among the subjects by
their occupation in Benin City and its environs. Drivers and traders (13.8% and 12.6%
respectively) show a significantly high rate of HIV-PTB co-infection (P < 0.05),
whereas there is no significant difference in the infection rate of HIV and PTB among the
various occupations (P >0.05).
Table 6: Distribution of HIV and PTB by occupation of subjects in
Benin City
Occupation |
n |
Number (%) of patients positive |
HIV alone (%) |
PTB alone (%) |
HIV-PTB (%) |
Non HIV/Non PTB (%) |
M |
F |
T |
M |
F |
T |
M |
F |
T |
M |
F |
T |
CS |
15 |
2 (13.3) |
0 (0) |
2 (13.3) |
5 (33.3) |
0 (0) |
5 (33.3) |
1 (6.7) |
0 (0) |
1 (6.7) |
5 (33.3) |
2 (13.3) |
7 (46.7) |
DR |
29 |
4 (13.8) |
0 (0) |
4 (13.8) |
10 (34.5) |
0 (0) |
10 (34.5) |
4 (13.8) |
0 (0) |
4 (13.8) |
11 (37.9) |
0 (0) |
11 (37.9) |
FM |
12 |
2 (16.7) |
0 (0) |
2 (16.7) |
4 (33.3) |
0 (0) |
4 (33.3) |
0 (0) |
0 (0) |
0 (0) |
6 (50) |
0 (0) |
6 (50) |
ST |
73 |
1 (1.4) |
7 (9.6) |
8 (11) |
12 (16.4) |
9 (12.8) |
21 (28.8) |
1 (1.4) |
0 (0) |
1 (1.4) |
22 (30.1) |
21 (28.2) |
43 (58.9) |
TR |
174 |
11 (6.3) |
28 (16.1) |
39 (22.4) |
12 (6.9) |
20 (11.5) |
32 (18.4) |
5 (2.9) |
17 (9.8) |
22 (12.6) |
35 (20.1) |
46 (26.4) |
81 (46.6) |
Total |
303 |
20 (6.6) |
35 (11.6) |
55 (18.2) |
43 (14.2) |
29 (9.6) |
72 (23.8) |
11 (3.6) |
17 (5.6) |
28 (9.2) |
79 (26.1) |
69 (22.8) |
148 (48.8) |
Key: As in Table 5
In comparing the incidence of HIV and PTB in Benin and its environs
with Irrua and its environs, there is no significant difference between the two regions
when the sex of the subjects are considered (P > 0.05). Whereas, subjects aged 60 years
and above have significantly high level of PTB in Benin (28.6%) than their counterparts in
Irrua (0%, P < 0.05), there is however no significant difference in the incidence of
HIV and PTB by occupation of subjects from the two regions (P >0.05).
This study revealed HIV infection rate of 18.2% and 12.7% for Benin
and Irrua environs respectively, while the male to female ratio of the HIV infection were
1 to 1.8 and 1 to 2.5 respectively. Report from some places in Nigeria show HIV prevalence
rate to be over 10%15 while studies in Uganda and Zaire showed that HIV in
women outnumbered that of men by 1.2.16 The differences in the infection rate
in females and males could be as a result of biological factors such as higher
susceptibility to infection and behavioural factors such as early exposure to sexual
activity that is common to women due to economic circumstances. Another reason could be as
a result of various customs in African countries, women are subordinated to their husbands
and as such do not have much say in issues related to sexual relationship.
HIV-PTB infection rate recorded in Irrua (10.8%) and Benin (9.2%) is in
agreement with reports by Idigbe et al.,17 Onipede et al.,18
and Okogun et al.19 Idigbe et al.,17 reported HIV-PTB
co-infection rate of 5.2% from Lagos State, while Onipede et al.,18
reported 12.9% from Ile-Ife, Ogun State. Okogun et al.,19 also reported
a prevalence rate of 5.3% from Abeokuta and environs in Ogun State.
The HIV-PTB co-infection in this study is however low when compared
with reports from other parts of the globe. Studies among TB patients in New York City,
Miami, San Francisco and Seattle show HIV prevalence of 30 – 50%.21,20,22 The
lower rate of HIV-PTB recorded in this study may be due to sampling method. The American
investigators based their studies on known PTB patients, most of whom might be homosexual
and intravenous drug abusers, and are thus more likely to be HIV positive.
The higher co-existence of HIV-PTB recorded among females from the two
regions is probably related to higher incidence of HIV infection that predisposed the
females to tuberculosis. HIV has been recognized to play an important role in the
activation of dormant tuberculosis.23
The significantly high HIV-PTB co-infection among drivers (13.8%)
and traders (12.6%) in Benin environs, and its higher rate among drivers in Irrua (22.2%)
suggests a higher exposure of HIV and infective droplets among these people who often
travel to different places.
The significantly high PTB infection among age-group < 20
years old in Benin (50%) and 21–30 years in Benin and Irrua (28.7% and 40%
respectively) could be as a result of increase in exposure to infection droplets when
these people go out for daily activities. It has been reported that majority of TB cases
occurred between the ages of 15–59 years.10
Although, this study was carried out in the chest clinics from
two regions of Edo States (Benin environs and Irrua environs), it should be noted that
there is no significant difference in the incidence of HIV, PTB and HIV-PTB in the two
regions. Whereas, the significantly high incidence of PTB recorded among people above 60
years in Benin region could be as a result of higher population (urban region), which
inadvertently increases the number of infective droplets in the atmosphere.
Recommendations
The co-existence of HIV and tuberculosis has been seen as one of
the most serious threats to human health24 because HIV positive person already
infected by M. tuberculosis has an 8% chance of developing overt disease within a
year or up to 50% chance during the remainder of their relative short life span.25
The future impact of HIV infection on tuberculosis worldwide will depend on changes in the
annual tuberculosis infection rate, the prevalence of infection by the tubercle bacillus
in the at-risk age group and the prevalence of HIV infection.2 Since increase
in HIV infection rate leads to increase in tuberculosis disease, there is need to
re-examine the strategies for their effective control. The most important aspect of this
control programme is public awareness and good health education on how tuberculosis and
HIV are transmitted.
The control of tuberculosis should involve measures which are aimed at
identifying and controlling the sources of infection, preventing reactivation of
tuberculosis in people at higher risk, treatment of diseased individuals and public
enlightenment.
- Stylblo K. The global aspects of tuberculosis and HIV infection. Bull. Int. Union
Tuberc. Lung Dis. 1990; 65:28-32.
- Grange JM. Tuberculosis. In: Topley and Wilson’s Micropbiology and Microbial
Infections. 9th edition, Vol. 3. Hausler, WJ. Jr. and Sussman, M. (ed.). Oxford
University Press, 1980; pp. 391–417.
- International Union Against Tuberculosis and Lung Disease (IUATLD) Tuberculosis and HIV.
In: Management of Tuberculosis, a guide for low income Countries. Fifth edition. 2000.
- Escott S, Nsuteby E, Walley J, Khan A. Management of TB in countries with high HIV
prevalence. African Health. 2001;23(3):12-15.
- DeCock KM, Sero B, Coulibaly IM, Lucas, SB. Tuberculosis and HIV infection is Sub-Sahara
Africa. JAMA. 1992; 278: 1581-1587.
- Nunn P. Impact of interaction with HIV. In: Porter JDH. and McAdam KPWJ. (eds.)
Tuberculosis: Back to the Future. Wiley, Chichester, 1994; pp. 49–52.
- Festenstein F, Grange JM. Tuberculosis and the acquired immune deficiency syndrome. J
Appl.Bacteriol. 1991;71:19-30.
- Osborn L., Kunkel S, Nabel GJ. Tumor necrosis factor and interleukin stimulate the human
immunodeficiency virus enhancer by activation of the nuclear factor Kappa B. Proc.
Natl. Acad. Sci. 1989;86:2230–2240.
- Onwuballi JK, Edwards AJ, Palmer L. T4 lymphopenia in human tuberculosis. Tubercle.
1987;68: 195–200.
- Horne N. Tuberculosis and other mycobacterium diseases. In: Mandell G, Douglas R,
Bennett J. (ed.) Principles and Practice of Infectious Diseases 3rd edition.
New York. Churchill Livingstone, 1996; pp. 971–1015.
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