To determine whether increased dietary iron could be a risk factor for active tuberculosis, dietary iron history and human immunodeficiency virus (HIV) status were studied in 98 patients with pulmonary tuberculosis and in 98 control subjects from rural Zimbabwe. Exposure to high levels of dietary iron in the form of traditional beer is associated with increased iron stores in rural Africans. HIV seropositivity was associated with a 17.3-fold increase in the estimated odds of developing active tuberculosis (95% confidence interval [95% CI], 7.4-40.6; P<.001), and increased dietary iron was associated with a 3.5-fold increase (95% CI, 1.4-8.9; P=.009). Among patients treated for tuberculosis, HIV seropositivity was associated with a 3.8-fold increase in the estimated hazard ratio of death (95% CI, 1.0-13.8; P=.046), and increased dietary iron was associated with a 1.3-fold increase (95% CI, 0.4-6.4; P=.2). These findings are consistent with the hypothesis that elevated dietary iron may increase the risk of active pulmonary tuberculosis.

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SummaryOBJECTIVE To elucidate the relationship between HIV, CD4 ϩ count and pleural TB. METHOD In a prospective study, 94 patients presenting at two large Harare hospitals with clinically suspected pleural TB were enrolled over a 10-month period. All underwent standardized evaluation, closed pleural aspiration and biopsy. Patients receiving directly observed anti-TB therapy were followed-up. RESULTS Pleural TB was diagnosed in 90 individuals (median age 33 years; range 18-65; 64 males); the seroprevalence of HIV was 85%. HIV-positive patients were older than HIV-negative individuals (median age 33 vs 23 years, P ϭ 0.013) and had a significantly lower median CD4 ϩ count (191 vs 1106 ϫ 10 6 /l respectively, P ϭ 0.004). A CD4 ϩ count of Ͻ200 ϫ 10 6 /l was associated with a length of illness Ͼ30 days (65% vs 37%; P ϭ 0.05), a positive pleural fluid smear (37% vs 0%; P ϭ 0.0006) and a positive pleural biopsy Ziehl-Neelsen stain (35% vs 7%; P ϭ 0.021). However, a relationship between CD4 ϩ count and either pleural granuloma formation or radiological evidence of disseminated disease was not observed. CONCLUSION In sub-Saharan Africa, TB pleural effusions have become associated with older age, a chronic onset, and an increased mycobacterial load. These data emphasize the complex relationship between pleural TB, HIV infection and a low CD4 ϩ count.keywords pleural tuberculosis, HIV, granuloma, CD4 lymphocyte, Zimbabwe correspondence R. S.Heyderman,