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ASSESSMENT OF PULMONARYTUBERCULOSIS IN PATIENTS

Atul Shah*, P PMehrotra**, Hl Dhar***
*Statistician; **Medical Records Officer; ***Director Research, Bombay Hospital Trust, Mumbai - 20.

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Case papers of 240 in patients (Bombay Hospital) suffering from pulmonary TB were analysed. 144 patients (60%) were adults, 51 (21.25%) were elderly. 166(69.16%) were males and 74 (30.84%) were females. 202 (84.17%) were Hindus and remaining were Muslims 20 (8.33%) and Christian 16 (6.67%). 113 patients (47.08%) were admitted in general ward of the hospital, rest in paying wards. 16 patients (6.67%) expired during hospital stay out of which 14 were diagnosed as pulmonary TB, 2 pleural effusion, 2 bronchopneumonia; 1 corpulmonale. 36 patients gave history of smoking and 22 of taking alcohol. 11 patients gave a family history of pulm TB. Hospital stay ranged from 1 to 2 weeks for 182 patients (75.84%). 4 patients had undergone surgical procedures mainly bronchoscopy during hospital stay.

Other associated conditions were diabetes (37) and urogenital (25), CVS (23), GI (22), Blood and Lymph (8), orthopaedic (7) and endocrine disorders (4). 58 (24.17%) patients in the past and 211 (87.92%) in the hospital received Anti Koch’s treatment. Majority (91%) received four anti TB drugs, some received three (4%) and even two (5%). Only 3 patients had adverse effect of raised liver enzymes. Sputum examination report was available in 102 patients of which AFB was found positive in 54 patients. X-ray findings consisted of infiltration, cavitation, consolidation, fibrosis / opacity, pleural effusion, pheumonitis and hylar-prominence etc. in 94 patients.

Thirty five patients (18.7%) were found anaemic and in 103 (42.91%) patients ESR was raised. In 12 (5%), total protein was found below normal.

 

INTRODUCTION

One third of world’s population is already infected by Tubercle Bacilli. Left untreated one person with active TB will infect 10-15 people in a year. Like common cold, tuberculosis spreads through air and relatively causal contact. WHO has declared tuberculosis as global emergency with operational targets of least 85% cure rates of diagnosed cases and detection of least 70% estimated cases.

World wide an estimated 2 billion people carry the organism mycobacterium tuberculosis. Around 80% of TB cases are in economically productive age group of 15-49 years. Prevalence rate 94.4 per lakh population was recorded in 1994 for whole South East Asia Region (SEAR) i.e. 0.094%. According to latest statistics (1994) there are total of 11, 14, 374 tuberculosis cases in India1 of which 87,783 belong to Maharashtra out of which 1250 died. [2] Children are the most vulnerable group, 1.7 lakh children dies of TB every year in SEAR. In India 40% of the children by the age of 6 years and 80% by the age of 16 gather tubercular infection. [3]

TB is the leading killer of HIV positive people. In 1996, it was estimated that 2.66 lakh HIV positive people will die due to TB in SEAR. [1]

It has been estimated that maximum number of TB patients in the world are in India and the rate of treatment failure is alarming. [4]

Present work is the analysis of data of patients suffering from tuberculosis admitted to Medical Research Centre of Bombay Hospital in a single year (1995) in order to ascertain hospital statistics of pulm. TB; disease pattern, associated conditions including treatment.

METHODS

Case papers were analysed and detail history namely age, sex, religion, class of admission, total hospital stay, family history, habits, present complaints and findings, past illness, operative history, biochemical and other investigations, including types of treatment received were recorded.

Out of 26,157 admissions 240 (0.91%) were labelled as suffering from pulm. TB as per ICD code 011 (WHO; Geneva 1978).

RESULTS

Subjects were grouped into children (up to 12 years) adolescent (13-21 years), adults (22-59 years) and elderly (60+ years). Demographic details has been shown in Table 1. 49 patients (20.42%) had some habits of which 22 were used to take alcohol, 36 smoking, 9 tobacco chewing and 1 each was taking pan masala and ganja.

 

TABLE 1 Demographic variables
Variables	Nos.	%
Age group	23
Paediatrics	22	9.59
Adolescent	144	9.16
Adults	51	60.00
Elderly		21.25
Sex
Male	166	69.16
Female	74	30.84
Religion
Hindu	202	84.17
Muslim	20	8.33
Christian	16	6.67
Others	2	0.83

 

Twelve patients gave family history of diseases of which 11 were suffering from TB, 2 from asthma and 1 from hypertension. Hospital stay varied from day 1 to more than 6 weeks. But majority i.e. 182 patients (75.84%) stayed for 1 to 2 weeks.

During hospital stay 34 patients had undergone surgical procedures mainly bronchoscopy 28, lobectomy 1, pleural tapping 4 and lung biopsy 1.

Eighty patients gave past history of Koch’s infection of which 54 were adults. Past history of cold/cough was found in 4 patients, breathlessness in 4, pleural effusion in 2, blood in sputum 1, diabetes in 44, hypertension and GI problems in 18 each. One patient was HIV (+) and two were suffering from carcinoma of lung and breast.

Present complaints were identified system wise e.g. resp. system - cough/cold 129, fever 148, breathlessness 59, pain in chest 45. Blood in sputum 26, pleural effusion 3.

Other general signs and symptoms were loss of appetite in 77, weight loss 56, weakness 34, diabetes 44, GI symptoms in 56, CNS in 20, orthopaedic and urogenital problems in 21 each.

On examination, foreign sounds (viz rales, rhonchi, crepitations) were found in 80 patients, reduced breath sounds in 9, pallor/anaemia in 29 oedema in 6, jaundice in 3, enlarged liver in 10 and meningeal signs in 6. Patients suffering from other diseases have been shown in Table 2. System wise they were grouped as suffering from CVS 23, diabetes 37, urogenital disorder 25, GIT disturbance 22, blood and lymph 8, orthopaedic problems 7, endocrine disorders 4 and others 11.

 

TABLE 2 Associated diseases
Diagnosis	Nos.	%
R.S.	230	95.83
General	11	4.58
C.V.S.	23	9.58
Cancer	4	1.67
Diabetes	37	15.42
C.N.S	14	5.83
G.I.	22	9.17
Orthopaedic	7	2.92
Urogenital	25	10.42
Blood and lymph	8	3.33
Sp. sens	2	0.83
HIV (+)	1	0.41
Endocrine	4	1.67

 

Out of 240 patients 58 (24.17%) received antiKoch’s treatment in the past and 211 (87.92%) patients were put on more than two antitubercular drugs. List of antitubercular drugs used has been listed in Table 3. Maximum number of patients (about 90%) received 4 antitubercular drugs at a time, some received 3 or even 2 (Table 4).

 

 

TABLE 3 Antitubercular treatment
Treatment	Past		Present
	Nos.	%	Nos.	%
Rifampicin	57	23.75	184	76.67
INH	56	23.33	209	87.87
Pyrazinamide	51	21.25	156	65.00
Ethambutol	51	21.25	98	40.83
ethionamide	—	—	5	2.08
Streptomycin	5	2.08	20	8.33

 

 

TABLE 4 No. of anti TB drugs intake by patients
Drugs intake	Past		Present
	Nos.	%	Nos.	%
Two	3	5.25	40	18.96
Three	2	3.45	90	42.68
Four	53	91.30	81	38.38
Total	58	100	211	100

 

No adverse drug reaction was reported except liver was found enlarged in 3 patients with marginal rise in liver enzymes.

Sputum was examined in 102 patients, and 48 patients were labelled as AFB positive.

X-ray reports were available for 94 (39.17%) patients and findings have been summarised in Table 5. 48 patients were found AFB positive, 94 had positive finding on X-ray out of which 28 were sputum positive.

Various laboratory findings have been detailed in Table 6. It was observed that 35 (18.7%) patients were anaemic and ESR was high in 103 patients. Total protein was low in 12 and cholesterol values were raised in 4 cases.

16 (6.67%) patients of pulmonary TB died during hospitalisation. Associated disorders or complications developed during the period resulting in death has been shown in Table 7.

 

TABLE 5 X-ray findings
Findings	Nos.	%
Infiltration	32	13.33
Cavitation	19	7.92
Consolidation	18	7.50
Pleural effusion	16	6.67
Fibrosis/opacity	12	5.00
Hilar prominence	10	4.47
Pneumonitis	5	2.08
Collapse	4	1.67
Emphysema	3	1.25
Hydropneumothorax	2	0.83
Lung abscess	1	0.42

DISCUSSION

Out of 240 patients suffering from pulmonary tuberculosis admitted in Medical Research Centre of Bombay Hospital nearly were male, 84%

 

TABLE 6 Causes of death
Causes	Nos.	%
C.R.A.	13	5.42
Pleural effusion	2	0.83
Bronchopneumonia	2	0.83
Core pulmonale	1	0.42
Diabetes	7	2.92
GI Disorder	4	1.67
CVS	3	1.25
CNS	3	1.25
Septicaemia	2	0.83

 

were Hindus, 8% were muslims and 6% were christians. Associated disorders were CVS 23 (9.88%), Diabetes 37 (15.42%). Urogenital 25 (10.42%) and GIT disorders 22 (9.17%), others 30 (12.5%), 58 (24.17%) received anti TB treatment in the past and nearly 90% while admitted in the hospital. No adverse drug reaction was observed during the hospital stay. X-ray reports were available in 40% with varying degree of involvement of lungs. Laboratory findings show high ESR in 72% with low protein in 8% but high cholesterol in 2.7%, however, 6.67% out of 240 died in the hospital.

Demographic data shows that male infected with TB is more than double compared to female. Exact data of male female ratio in the country is not available however, 70% of male subjects seem to be on the higher side possibly because male subjects got priority to the family to report to hospital and get admitted requiring high cost of treatment. Comparatively more of Hindus and Christians were admitted into this hospital which reflects on their economic status compared to Muslims. Diabetes constitute maximum (15.42%) among associated illness known to alter the immune status along with AIDS, [5] however, there was no patients in this series suffering from AIDS.

24.57% of the patients received antitubercular drugs in the past and 90% of all patients admitted received antitubercular regimen most of them receiving 4 or 3 drugs. There was no documented evidence of drug resistance and no adverse drug reaction was observed during hospital stay except enlarged liver with increased liver enzyme in a few patients, however, without any exacerbation of symptoms. Initial diagnosis was based on history and sign symptoms suspected to be of tuberculosis however, positive diagnosis could be made based on AFB positive sputum (48%) and positive X-ray findings (40%) showing varying degree of lung involvement. Laboratory findings could be an aid to diagnosis showing high ESR in 72%, anaemia 18% and low protein in 8%.

Sixteen patients (6%) died in the hospital. Although there is no comparable data available on mortality due to tuberculosis on hospitalisation. Present figure seems to be high. It is possible that only serious cases were admitted in this hospital.

REFERENCES

1. Malik Sanjiv. The threat of tuberculosis, Hospital today. Sept., 1996; I (10) : 9-17.
2. Health information of India. 1994.
3. Singh Varinder. The threat of tuberculosis, Hospital today. Sept., 1996; 1 (10) : 35.
4. Malik Sanjiv. The threat of tuberculosis, Hospital today. Sept., 1996; 1 (10) : 7.
5. Technical series, pulmonary tuberculosis. Ass. Physicians of India. 1994; 1-2.

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