HOT AND COLD TUBERCULOSIS SPECIALLY IN RAJASTHANI PATIENTS

HOT AND COLD TUBERCULOSIS SPECIALLY IN RAJASTHANI PATIENTS

O P Kapoor
Hon. Visiting Physician, Jaslok Hospital and Bombay Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008.

Text books differentiate between active and healed tuberculosis. Presence of symptoms of toxaemia and the shadow in the X-ray chest point to active lung tuberculosis. The raised ESR confirms it.

In private practice, this classification does not hold true. It is then better to divide tuberculosis in "Hot" and "Cold". The latter can also be called as "non-toxic tuberculosis" or "granulomatous tuberculosis".

As far as the physician is concerned, the symptoms of excessive sweating and rise of fever in the evening, loss of appetite and weight along with cough indicate active (hot) lung tuberculosis. Raised ESR will confirm the activity. Absence of symptoms of toxicity and a normal ESR in a patient having a shadow of a scar in the lung as seen in an X-ray chest indicate "healed" (cold) tuberculosis for which no treatment is given.

According to my classification, patients having active cold tuberculosis do not have symptoms, of toxicity. In fact, many of them are overweight and do not complain of fever and loss of appetite. ESR is often normal But the specialists try to manipulate the readings of ESR by showing readings around 25-35 mm which certainly are not abnormal. Really speaking, what the specialists are treating is a "granuloma". There are dozens of causes of non-tuberculous granuloma seen in different parts of the world Unless AFB are grown on culture, from the biopsy-specimen which is taken for histopathology, a diagnosis of TB granuloma can never be made hundred per cent.

Although I am convinced that many cases of granuloma in our country are "tuberculous" in aetiology, the practitioners should keep their minds open regarding the management of these patients specially since this may be only a reaction to tuberculous bacillus as has been suspected in the aetiology of sarcoidosis - a very common granuloma seen in UK where tuberculosis hardly exists.

A positive Mantoux test is seen in adults in hot and cold tuberculosis. But it does not help to diagnose activity. A negative result will definitely help to diagnose sarcoid granuloma.

Following is the treatment which has been advised by me for cold tuberculosis :

1. No treatment : Often when the other specialists have advised anti-tuberculous drugs, I have prescribed only a high calorie-high protein diet and a spontaneous cure has occurred. It is possible that in these cases, the aetiology of granuloma was not tuberculosis.

2. Anti-tuberculous drugs : While I have seen a number of cases recovering with this line of treatment, I am not convinced that these drugs can work equally well in a case of "hot" and "cold" tuberculosis. In fact, in a number of these cases it was later confirmed that these patients had been given additional "steroids" secretly or openly.

3. Anti-tuberculous drugs and steroids : All the specialists must prescribe steroids, in this so called "cold" tuberculosis. It is thus possible that the response seen is more often due to "steroids".

4. Only steroids : Often these patients respond only to steroids. This is because all the granulomas of any aetiology respond to steroids. Hepatic granuloma is a very good example.

5. Surgery : If the patient fails to respond to medical treatment, surgery may be done, if the lesion can be excised or altered.

Finally, this is the type of tuberculosis where the clinician must have an open mind even after a few weeks to few months of treatment. Even in retrospect, the doctor should be flexible and should not mind to change the diagnosis to non-tuberculous granuloma.

Before I discuss the subject of cold tuberculosis as I have seen in private practice, my advice is not to lean too much on the histopathological diagnosis. The residents should be trained that a part of every biopsy specimen should also be sent separately for culture for AFB, whether this tissue is from brain, liver, gland or pelvic organs. This is the only way in which advances in knowledge of cold tuberculosis can take place.

Following are the examples that I have seen in my private practice and I have labelled them as "cold tuberculosis". In fact, all such patients had extrapulmonary tuberculosis.

Neuro-physicians have been overdiagnosing tuberculomas in the brain after seeing the report of CT scan or MRI. Upto now, there is no fool-proof method to differentiate tuberculoma from non-tuberculous granulomas or parasitic granulomas (cysticercosis). This will explain the difference in response, in various patients treated as tuberculomas. On more than half a dozen occasions, I have seen that the patient had not taken anti-tuberculous drugs, but after a period of 3-4 months, the repeat CT scan showed that the granuloma had dissappeared.

In other cases, where steroids were prescribed (besides anti-tuberculous drugs), these seemed to have played a vital role.

Then how do we diagnose tuberculoma in future? Should we do "aspiration biopsy" of all brain tuberculomas and send it for culture for AFB? Yes. This will be ideal. But the scar produced by the biopsy can be a permanent focus for epilepsy!!

Gastroenterologists have been diagnosing tuberculous granulomas (tuberculomas) of the liver as a cause of PUO. Remember that the steroids must be added to the drug regimen. Also if the response to medical treatment is poor surgery should be offered and granuloma excised. (pulmonologists; diagnose "tuberculoma" on X-ray chest. At the autopsy, on many occasions, I have confirmed nodular, calcified shadow seen on an X-ray chest is nothing but a calcified bronchial, caseous secretion trapped due to bronchial stenosis with no element of active tuberculosis whatsoever).

General surgeons prescribe straightforward anti -tuberculous drugs for tuberculous glands of the neck.

It is worth noting, that addition of steroids or surgery is the only difference in the treatment of "lung" and "gland" tuberculosis.

Pelvic tuberculosis which is the most common cause of primary sterility in our country is diagnosed on laparoscopy by the gynaecologists. On more than one occasion, I have seen that after ]aparoscopy anti-tuberculosis drugs with steroids are being prescribed for primary sterility for women from upper class society, who are otherwise overnourished. They had to stop anti -tuberculous drugs because they became pregnant within a month! Sure enough, what the gynaecologist had seen on the scopy were non-tuberculous granulomas. But breaking of the thin adhesions might have helped therapeutically. In future, the only way to learn is to biopsy these granulomatous lesions and send them for culture of AFB.

Cardiac surgeons treat every constrictive pericarditis with anti-tuberculous drugs. This "cold" tuberculosis is only one of the causes of constrictive pericarditis. All other granulomas can also cause the same picture.

Ophthalmologists treat Eale's disease and phlyctenular conjunctivitis with anti -tuberculous drugs and steroids. It is likely that only steroids work.

When urologists treat a case of tuberculosis of kidney or ureter they are treating cold tuberculosis, and steroids must be added.

As far -as I am concerned as a physician, I would like to apply this knowledge to an underweight. Patient who comes from areas like Rajasthan (very prone to tuberculosis), but has no symptoms of fever, loss of weight and has a normal ESR. He could be having "cold" tuberculosis. Many physicians are tempted to give a therapeutic test with anti tuberculous drugs. Often I am successful in increasing the weight with appetisers and high caloric diet. I feel, till we learn, what is the scientific entity of "cold" tuberculosis, we are not justified in prescribing anti -tuberculous drugs to these patients, sepcially because, I would then add steroids to the treatment.

In conclusion, I have labelled "hot tuberculosis" as the one where there are symptoms of toxicity like fever, loss of appetite and weight; ESR is often markedly raised and AFB are easy to demonstrate. Best example is pulmonary tuberculosis.

In "cold tuberculosis" there are usually no symptoms of toxicity; ESR is often borderline elevated or normal; AFB are often not demonstrated; the response to treatment with anti koch's drugs is seen only when steroids are added. Best example is extra pulmonary tuebrculosis

In some patients, there could be overlap of the two types of tuberculosis.