Indian Journal of Tuberculosis

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Role of socio-economic factors in tuberculosis prevalence.
(2004-01) Gupta, Dheeraj; Das, Kshaunish; Balamughesh, T; Aggarwal, Ashutosh N; Jindal, Surinder K
Background: There is a need to re-assess the role of generally identifiable risk factors for development of tuberculosis (e.g. old age, poverty and poor socio-economic status). The present study was designed to look into the socio-economic and demographic characteristics of patients of tuberculosis (TB) vis-à-vis those with other respiratory diseases in the area in and around Chandigarh. Setting: Chest Clinic of a tertiary care hospital. Design: Case-control study Material and Methods: Two hundred and fifty consecutive cases of TB and an equal number of patients with pulmonary diseases other than tuberculosis as controls were interviewed as per a pre-designed, structured questionnaire that inquired into several socio-economic and demographic variables besides the clinical details. Univariate and multiple logistic regression analyses were carried out to obtain odds ratios separately for each variable. Results: The mean age of patients suffering from tuberculosis was 35.56 years (SD 13.69). There were 168 men (67.2%) and 82 (32.8%) women among the cases. Persons suffering from tuberculosis were more frequently found to have the worst of the socio-economic conditions for all the variables. Odds ratio (OR) increased by 3.14 (95% CI 2.48-3.98, p<0.001) for every decrease of Rs.500/- in the income level per person per month below Rs.2000/-. Similarly, the OR increased by 3.66 (CI 2.9-4.61,p<0.001) with increasing number of persons per room. The ORs for poorer housing, toilet facilities, water supply and consumer articles were also significant. In multivariate logistic regression analysis, the age, level of education, crowding, type of housing, water supply and number of consumer articles in the household was found to be independently and significantly associated with a higher risk of TB. Conclusion: There is a significant SES-health gradient in TB prevalence; tuberculosis risk increases with lowering of socio-economic status.
Multi-drug resistant extra-pulmonary tuberculosis in a HIV negative patient.
(2004-01) Sharma, S K; Mohan, A
A 25 year-old, HIV seronegative male presented with bilateral cervical lymphadenopathy with cold abscesses and sinus formation, peripancreatic lymphadenopathy and hypodense lesions in the spleen. Culture of pus aspirated from the cold abscess in the neck grew M.tuberculosis resistant to Rifampicin, Isoniazid, Ciprofloxacin and Para-aminosalicylic acid. In a resource-limited setting, he was treated with Ethambutol (E), Pyrazinamide (Z), Ethionamide (Eth), Cycloserine (Cyc), and Ofloxacin (Ofl). While on treatment, he developed drug induced hepatotoxicity; Z and Eth were stopped and clofazimine was added to the regimen. Subsequently, he developed splenic abscess and clofazimine induced generalized pigmentation of the body including tongue. After eighteen months of treatment, lymphadenopathy and splenic lesions regressed significantly. Thus, present case highlights several important basic principles of management of MDR-TB such as procuring tissue for microbiological testing, judicious use of imaging modalities, careful monitoring for adverse drug reactions, intercurrent infections and the need for pretreatment counselling for ensuring compliance and completion of treatment.
A 35-year old man with a non-resolving pleural effusion.
(2004-01) Panjabi, Chandramani; Khanna, Puneet; Jain, Sudhir; Shah, Ashok
A thirty-five-year old male, a nonsmoker, was referred to us for evaluation of progressive pulmonary disease. His clinical course during the past 2 years was characterized by paroxysmal attacks of cough with scanty mucoid sputum. This was accompanied by intermittent fever and malaise. There was no history of wheezing, nasal symptoms or loss of weight. Eighteen months prior to referral, based on his symptomatic and roentgenologic profile, he was clinically diagnosed as a case of tuberculous mediastinal lymphadenitis. He was initiated on antituberculous therapy (ATT) comprising rifampicin 450 mg, isoniazid 300 mg, pyrazinamide 1500 mg and ethambutol 800 mg once daily. Prednisolone (10 mg thrice daily) was added after 2 months when the patient did not experience any relief. He was however irregular with the oral steroids and stopped it after 1 month. One year prior to referral, while on ATT for 6 months, he had few episodes of blood-streaked sputum, episodic exertional dyspnoea, and rightsided chest pain that increased on coughing and deep breathing. This was diagnosed as right-sided pleural effusion, and the patient was initiated on second line ATT in the form of kanamycin 1gm intramuscularly, sparfloxacin 400 mg, prothionamide 750 mg, clofazamine 200 mg, clarithromycin 500 mg, thiacetazone 150 mg and isoniazid 300 mg once daily. Kanamycin was stopped after 6 months but the other drugs were continued for a period of 1 year. In spite of regular second line ATT for 1 year, the patient remained symptomatic and as the effusion persisted, he was referred to us for evaluation. Physical examination revealed a middle-aged male in no acute distress. There was no clubbing or cyanosis. Chest examination suggested a right-sided pleural effusion. Examination of other systems, including an ophthalmologic referral, did not detect any abnormality.
Status Report on RNTCP.
(2004-01) Indian Journal of Tuberculosis
Paraffin slide culture technique for isolating non-tuberculous mycobacteria from stool and sputum of HIV sero-positive patients.
(2004-01) Narang, P; Narang, Rahul; Bhattacharya, S; Mendiratta, D K
Objective: Paraffin slide culture method (PSC) was used to isolate Non-tuberculous mycobacteria (NTM) from stool and sputum samples of HIV seropositive and negative patients. Material & Methods: Eighty stool and forty two sputum samples from both symptomatic or asymptomatic HIV sero-positive patients; and 40 stool and 128 sputum samples from symptomatic but HIV seronegative patients were cultured by PSC to assess its utility in isolating NTM from the clinical specimens. The samples were simultaneously processed by culture on Lowenstein Jensen (LJ) medium for comparison with regard to isolation rate, isolation time and contamination rate. Results: The PSC proved to be as good as LJ in isolating NTM from clinical specimens and, in addition, had the advantage of in situ staining for acid fast bacilli and lower contamination rate. The PSC was also used for typing NTM by biochemical tests.
Tubercular Osteomyelitis of nasal bones A rare entity.
(2004-01) Wadhera, Raman; Kumar, Avinash; Gulati, S P; Arora, Sanjeev
A case of tubercular osteomyelitis of nasal bones in a 10 year old child is being reported because of its extremely rare occurrence.
Co-infection of Human Immunodeficiency Virus (HIV) and Tuberculosis: Indian Perspective.
(2004-01) Sharma, S K; Mohan, A
Human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) have resulted in a resurgence of tuberculosis the world over. Given that the South-East Asia Region of the World Health Organization accounts for nearly 40 per cent of all tuberculosis (TB) cases globally and 18 per cent of the world’s HIV infected also live in this region, the twin challenge of this “cursed duet” seems to be daunting. Treatment of patients coinfected with HIV and TB in India is very difficult especially because there is very little co-ordination between the Revised National Tuberculosis Control Programme (RNTCP) and HIV control. Clinical presentation of TB in early HIV infection resembles that observed in immuno-competent persons. In late HIV infection, the clinical presentation of TB can be atypical. Diagnosis of TB in HIV infected patients may be delayed because of atypical clinical presentation and involvement of inaccessible sites and low sputum smear positivity. Rational management of patients co-infected with HIV and TB in severely resource limited settings involves detailed history taking, thorough physical examination, clinical staging, assessment of CD4+ T-lymphocyte count or total lymphocyte count and institution of antiretroviral drugs and antituberculosis treatment using the directly observed treatment, short-course (DOTS) strategy. HIV infected patients respond well to the standard anti-tuberculosis drug treatment regimens using the DOTS strategy. Thorough knowledge and familiarity regarding the adverse drug reactions and drug-interactions between antiretroviral and anti-tuberculosis drugs is essential for ensuring compliance and successful outcome.
MDR TB - Current Issues.
(2004-01) Singh, M M; Chopra, K K
Initial Drug Resistance among tuberculosis patients under DOTS Program in Bangalore city.
(2004-01) Vijay, Sophia; Balasangameshwara, V H; Jagannatha, P S; Kumar, P
Background & Objectives: The level of initial drug resistance (IDR) and its trend is a sensitive indicator of the programme efficiency and provides indirect reflection of the quality of tuberculosis services in the area. Studies from some parts of India have reported an increase in the level of IDR to INH and Rifampicin. There is paucity of information on age specific pattern of IDR from India. Frequency of drug resistance in the younger age group provides a precise evaluation of the current situation. The published data from Bangalore (1985-86) pertaining to patients under the National TB programme reported an IDR of 20.6% to any drug. Subsequently, the RNTCP with DOTS strategy to achieve high cure rate was implemented in the area in late 1998. The present study was undertaken in a cohort of 324 new smear positive patients initiated on Cat-I regimen under RNTCP in Bangalore Mahanagara Palike from April to December 1999 to study the pattern of IDR among them, soon after RNTCP implementation in the area. This information would serve as a useful baseline data for the area to assess the impact of DOTS strategy on the levels of IDR subsequently. Material & Methods: Two pre-treatment sputum samples were collected from these patients and subjected to microscopy, culture & susceptibility testing at the National Tuberculosis Institute. The susceptibility testing was done by economic version of proportion method, as per IUATLD guidelines. Information regarding the previous treatment was elicited using a pre-tested semi-structured schedule based on the WHO questionnaire for IDR surveillance and scrutiny of available records. Results: Among the 271 correctly categorized new patients, 27.7% were resistant to one or more drugs. The resistance to streptomycin was highest (22.5%) followed by INH (13.7%), and MDR was 2.2%. The age specific resistance was highest in <25 years and declined significantly in the higher age groups, being lowest (17.7%) in >45 years. Effective RNTCP implementation is expected to show declining trends in the IDR, particularly in the younger age group during the subsequent surveys.
Outcome in multi-drug resistant tuberculosis patientswith ambulatory treatment.
(2004-01) Rai, S P; Panda, B N
Background: Multidrug resistant tuberculosis (MDR-TB) is emerging as an increasingly important cause of morbidity and death. The patients continue to spread disease for a prolonged period and may pose a threat to the success of DOTS. Aim: To evaluate response to chemotherapy with second line drugs given on domiciliary basis in cases of MDRTB. Methods: Retrospective case records of 36 proven MDR-TB patients treated from April 1998 to April 2001 were analyzed. The patients were defined as cured when they had continued to be smear and culture negative for more than one year in addition to clinical and radiological improvement. All patients were followed up for relapse for one year. Results: Out of 36 patients, 27 had far advanced lesions and 8 had moderately advanced lesions. All patients had resistance to at least Isoniazid and Rifampicin. Additional resistance was observed to Streptomycin in 19, Pyrazinamide - 8, Ethambutol - 8, Ethionamide - 6, Cycloserine - 5, Thiacetazone - 4, Ciprofloxacin- 3 and PAS in one patient. Average duration of pre-treatment chemotherapy was 14 months. Twenty patients were cases of relapse. Ten patients had concomitant disease (NIDDM - 3, COPD-4, Bronchial asthma-2, IHD-1). Average time for sputum conversion was 5 months. Twenty-three patients had sputum conversion in less than 4 months after revised chemotherapy. Out of 36 patients, 28 patients were declared cured at the end of 24 months of therapy, 7 patients defaulted and one patient died due to massive haemoptysis. Adverse reactions to chemotherapy included photosensitivity to Sparfloxacin-4 patients, ototoxicity to Kanamycin-2 patients and hyperuricemia- one patient. Conclusion: Problem of MDR-TB can be managed to some extent by ambulatory treatment with other logistic supports like drugs, laboratory services and sympathetic motivated staff.
Status Report on RNTCP.
(2004-04) Indian Journal of Tuberculosis
A report on the 34th IUATLD World Conference on Lung Health, Paris.
(2004-04) Indian Journal of Tuberculosis
Importance of blood samples for diagnosis and drug sensitivitytesting in HIV positive patients with suspected tuberculosis.
(2004-04) D'souza, Desiree T B; Birdi, Tannaz J; Dholakia, Yatin; Hira, Subhash; Antia, Noshir H
Background: Diagnosis of tuberculosis is difficult in HIV positive patients since they often present with atypical symptoms and are susceptible to pulmonary infections that mimic tuberculosis. Sputum collection may not be possible even in patients with pulmonary involvement since a productive cough is not always present. In such patients, blood smear and culture for AFB apart from serving as a diagnostic tool can be used for testing drug sensitivity. Objectives: This study was undertaken to explore the value of blood culture for diagnosis in patients with suspected TB. In addition, a comparison of drug sensitivity patterns of blood and sputum isolates in 10 of these patients was also carried out. Methods: Blood and sputum samples were processed, cultured and isolates tested for their drug susceptibility and for niacin production, nitrate reduction as well as catalase activity at 68o C. Results: All 24 blood samples were culture positive although only 6 were smear positive. On the basis of the biochemical investigations, 22 strains were identified as Mycobacterium tuberculosis. All the 10 sputum samples were culture positive despite 4 being smear negative. Comparison of drug sensitivity profiles from blood and sputum revealed concordance to five first or second line drugs in 5 of 10 patients. Additionally, 2 patients demonstrated discordance for only one first or second line drug. Conclusion: The study demonstrates the importance of blood culture in confirming diagnosis of tuberculosis and testing for drug sensitivity in HIV positive patients without a productive cough. The level of discordance in drug sensitivity profiles between blood and sputum the same individual is suggestive of infection with multiple strains. Testing for the occurrence of multistrain infections through individual colony examination of a single isolate is necessary since such infections would affect treatment of non-responder patients having HIV-TB dual infections.
Fungal infections of lungs the emerging scenario.
(2004-04) Panda, B N
Fungal infections of lungs are important infective processes which are being encountered more and more often in today’s practice. Fortunately, we only encounter a few of these pathogenic fungi. With more and more people undergoing organ transplantation and cytotoxic therapy, chances of encountering these diseases are steadily increasing. Though treatment is difficult, nevertheless, the results are encouraging. Hence, it is all the more important today to know these diseases well so that we are able to manage them scientifically. Diseases like ABPA, if diagnosed early, can be treated effectively so as to prevent progression to fibrotic stage and reduce the number of respiratory cripples. Invasive systemic mycosis is also amenable to multimodal therapy. With advent of newer imidazoles and newer modalities of drug delivery like liposomal amphotericin B, the so called complicated treatment modalities can be further simplified. Prophylaxis is today available for preventing PCP in immunocompromised patients and they need to adhere to prophylaxis.
Inter-Sectoral Cooperation for Success of the RNTCP.
(2004-04) Agarwal, S P
HLA-DR phenotypes and lymphocyte response toM. Tuberculosis antigens in cured spinal tuberculosispatients and their contacts.
(2004-04) Kurian, Sunil Mathan; Selvaraj, P; Reetha, A M; Charles, N; Narayanan, P R
Background: Our earlier studies on Human Leucocyte Antigens (HLA) in pulmonary tuberculosis patients revealed the association of HLA-DR2 antigen with susceptibility to pulmonary TB and DR2 antigen has been shown to influence the immunity to tuberculosis. Objectives: The present study was carried out to find out whether HLA-DR antigens are associated with susceptibility to spinal tuberculosis. Moreover, the role of HLA-DR antigens on lymphoproliferative response to Mycobacterium tuberculosis culture filtrate antigens was studied using Lymphocyte Transformation Test (LTT). Material and Methods: HLA-DR genotyping and lymphoproliferative response was carried out in 63 cured spinal TB patients and 63 control subjects (spouses of pulmonary and spinal TB patients). Results: A trend towards an increased frequency of HLA-DR9 antigen was observed in spinal TB patients compared to controls. A significantly decreased lymphocyte response to M. tuberculosis antigens was observed in HLA-DR9 antigen positive control subjects compared to HLA- DR9 antigen negative subjects (P=0.0009) whereas increased response was observed with DR9 positive cured spinal TB patients compared to HLA-DR9 antigen negative patients. Further, HLADR3 antigen positive patients showed a decreased lymphocyte response compared to HLA-DR3 antigen negative patients (P<0.05). Conclusion: The study suggests that HLA-DR9 antigen either alone or in combination with other HLA antigen as lhplotype and non-HLA genes may be associated with susceptibility to spinal TB and play a regulatory role on the immune response to M. tuberculosis in spinal tuberculosis patients.
Tuberculosis in the elderly and their treatment outcome under DOTS.
(2004-04) Gaur, S N; Dhingra, V K; Rajpal, S; Aggarwal, J K; Meghna
Summary: A retrospective study of the profile and treatment outcome in the elderly TB patients taking DOTS was carried out in an urban TB clinic of Delhi. Out of 2118 tuberculosis patients treated between 1999-2001, a total of 238 (11.4%) patients were over 50 years of age and of these 45(2.2%) were over 65 years of age. A total of 78.6% of the 283 TB patients of all the categories included in the study had a successful outcome (cure/ completion). The overall case fatality, default and failure rates among the TB patients over 50 years were found to be 7.1%, 8.8% and 4.6%, respectively, despite directly observed treatment being given under RNTCP. The case fatality rate was significantly higher (15.6%) in the age group >65 years as compared to patients between 50-65 years (5.2%). The failure rate was significantly higher (13.3%) in the age group >65 years than among patients in the 50-65 years age-group (2.6%). This emphasizes the need for intensive motivation and stringent monitoring among tuberculosis patients over 65 years of age.
Diaphragmatic paralysis and hoarseness of voice due to mediastinal tuberculous lymphadenitis.
(2004-04) Gupta, Prem Parkash; Gupta, K B; Yadav, Rohtash; Agarwal, Dipti; Sood, S
The most frequent cause of diaphragmatic paralysis and hoarseness of voice is involvement of phrenic nerve and recurrent laryngeal nerve by a thoracic malignancy. Here, we describe a patient who developed diaphragmatic paralysis and hoarseness of voice due to mediastinal tuberculous lymphadenopathy, which is not a common etiological factor leading to it.
Pulmonary Tuberculosis with Pancoast Tumour.
(2004-04) Acharya, K Vishak; Sahoo, Rameshchandra; Anand, R; Kumar, Ashvini
A 56 year old man presenting with complaints of pain chest with radiation to the right arm and haemoptysis was found to have a right upper zone mass lesion with rib erosion on the X-ray chest, fine needle aspiration cytology of which revealed squamous cell carcinoma. Subsequently, sputum smear was found to be positive for acid fast bacilli by Ziehl Neelsen stain. Synchronous presence of Pancoast tumour of the lung with active pulmonary tuberculosis in the same lobe is a very rare association. To our knowledge, there has been no previous report of any similar case in literature.
Fifty Eighth National Conference on Tuberculosis and Chest Diseases A Brief Review.
(2004-04) Singh, M M

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