Management of the Coadministration of TB and HIV Therapies, Including the Potential for Paradoxical Reactions
When antituberculosis treatment has been started, all patients should be monitored for response to antituberculosis therapy, drug-related toxicity, and drug interactions. Detailed recommendations for managing antiretroviral therapy are published elsewhere (4), and consultation with experts in this area is highly recommended.

The frequency and type of most TB medication side effects are similar among TB patients with and without HIV infection (30,65,67). When caring for HIV-infected persons, clinicians must be aware of the following problems that can result from the administration of TB medications: a) patients might have a higher predisposition toward isoniazid-related peripheral neuropathy; b) evaluation of dermatologic reactions related to TB medications might be complicated because HIV-infected patients are subject to several dermatologic diseases related to HIV disease or to medications used for other treatment or prophylaxis reasons; and c) patients undergoing concurrent therapy with rifabutin and protease inhibitors or NNRTIs are at risk for rifabutin toxicity associated with increased serum concentrations of this drug. The reported adverse events associated with rifabutin toxicity include arthralgias, uveitis, and leukopenia (86,101-103). Detailed recommendations for managing these adverse reactions are published elsewhere and should be consulted (2,64).

Paradoxical reactions -- temporary exacerbation of symptoms, signs, or radiographic manifestations of TB (e.g., recurrence of fever, enlarged lymph nodes, appearance of cavitation in previously normal chest x-ray) among patients who have experienced a good clinical and bacteriologic response to antituberculosis therapy -- have been reported among patients coinfected with HIV who have restored immune function because of antiretroviral therapy (76). The synchronization and severity of paradoxical reactions associated with antiretroviral therapy are not well understood; therefore, experts do not know whether the occurrence of these reactions should affect the timing of initiating or changing antiretroviral therapy when such therapy is indicated for a patient with HIV infection. However, because an association between paradoxical reactions and initiation of antiretroviral therapy has been noted, clinicians should be aware of this possibility and discuss the risks with patients undergoing therapy for active TB.

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