Diagnostic challenge of tuberculosis of the elderly in hospital: experience at a university hospital in Saudi Arabia

Pulmonary tuberculosis in a cohort of forensic autopsies: a preliminary study from Saudi Arabia

Aims

The purpose of this study was to identify any cases of previously undiagnosed pulmonary tuberculosis during autopsy.

Methods

This prospective study investigated a cohort of deceased individuals that underwent a full external and internal postmortem examination at the Forensic Medicine Centre, Dammam, Saudi Arabia. Gross pathology, histopathology and molecular pathology were used to identify pulmonary tuberculosis in forensic autopsy samples from the lungs.

Results

A total of 82 cases autopsied were included in the study. The mean ± SD age of the study cohort was 35.5 ± 10.3 years (range, 20–80 years). Males (n = 70; 85.37%) outnumbered females. The deceased were from 15 different countries. The number of Saudis was 16 (19.51%). The maximum number of non-Saudis was from India with 26 cases (31.71%). There were no cases of undiagnosed pulmonary tuberculosis detected for the first time at autopsy.

Conclusions

Although the prevalence of pulmonary tuberculosis in forensic autopsy cases in this preliminary study was nil, we recommend further studies to be conducted on a larger scale and in different autopsy centres throughout Saudi Arabia to get an insight into the burden of clinically undiagnosed tuberculosis in the entire country.

Survival of patients with multidrug-resistant tuberculosis in Central China: a retrospective cohort study

The aim of this study was to evaluate long-term survival and risk factors associated with multidrug-resistant tuberculosis (MDR-TB) patient survival in Central China. Between December 2006 and June 2011, incident and retreatment adult MDR-TB patients were enrolled in the present study. Cox proportional hazard regression analysis was used to evaluate the risk factors affecting survival. The total follow-up period was 270 person-years (PY) for 356 MDR-TB cases in Wuhan. Of the 356 cases, 103 patients died, yielding an average case fatality rate of 381.2 per 1000 TB patients per year. Using adjusted Cox regression analysis, older age (adjusted hazard ratio (aHR) >3.0 starting from 30 years) and low education level (primary and middle school; aHR 1.67 (95% CI 1.01–2.77)) were independently associated with lower survival. Diabetes mellitus profoundly affected the survival of MDR-TB patients (aHR 1.95 (95% CI 1.30–2.93)). Our data demonstrate that coexistent diabetes significantly and negatively impacted MDR-TB patient survival. In addition, MDR-TB patients aged 60 years or older exhibited a greater risk of mortality during follow-up. Our findings emphasise that MDR-TB patients with comorbidities that increase their risk of death require additional medical interventions to reduce mortality.

Delayed diagnosis of active pulmonary tuberculosis in emergency department

BACKGROUND AND PURPOSE

Tuberculosis (TB) is a worldwide health challenge. Emergency department (ED) is the major public access to the health care system. Delayed diagnosis of active pulmonary TB was believed to precipitate mortality and morbidity. The study was designed to investigate clinical characteristics and factors in patients with delayed diagnosis of active TB in ED.

METHODS

We used a retrospective chart review.

PATIENTS

A total of 103 patients were enrolled between December 2003 and March 2006.

RESULTS

Typical chest radiographic findings were noted in 79.8% of nondelayed TB group and 31.6% of delayed TB group (P < .001). Diagnosis of pneumonia was made at ED in 22.6% of nondelayed TB group and 68.4% of delayed TB group (P < .001). Length of initiation of TB treatment intervention was 0 days (0-1 days) and 9 days (6-16 days), respectively (P < .001). In-hospital mortality rate was 15.5% and 47.4%, respectively (P < .01). Age (odds ratio, 1.07; 95% confidence interval, 1.01-1.1) and intensive care unit admission (odds ratio, 5.01; 95% confidence interval, 1.18-21.3) were associated with lower in-hospital survival. Delayed ED diagnosis of TB was associated with mortality in results of univariate analysis (P = .002), but no statistical significance was noted in the final result of stepwise logistic regression analysis.

CONCLUSION

Intensive care unit admission and age are associated with mortality. Awareness of varying features of pulmonary TB by physicians is important.

The impact of age on the demographic, clinical, radiographic characteristics and treatment outcomes of pulmonary tuberculosis patients in Taiwan

BACKGROUND

The characteristics of pulmonary tuberculosis (TB) in the elderly are different from young patients. This leads to delay in diagnosis and higher mortality from TB in the aged population. The aim of this study was to investigate the impact of age on the demographic, clinical, radiographic characteristics, and treatment outcomes of pulmonary TB patients in Taiwan.

MATERIALS AND METHODS

We performed a retrospective analysis of the medical charts and chest radiographs of 83 elderly (> or =60 years old) and 74 young (< 60 years old) culture-proven pulmonary TB patients from 1 August 2003 to 31 July 2006.

RESULTS

Elderly patients showed lower frequencies of infectious TB contact history, alcoholism, cavity, and positive acid-fast bacilli sputum smears. In contrast, the elderly population had higher frequencies of chronic obstructive lung disease, heart failure, stroke, dyspnea, lower lung field involvement, pleural effusion and mortality. There were no differences between these two groups regarding sex, initial body weight, previous TB disease, hospital admission, diabetes mellitus, end-stage renal disease, neoplasm, liver cirrhosis, upper lung field involvement, cure, and treatment completion. Furthermore, age of 60 and older, lower initial body weight less than 50 kg, coexisting medical diseases, and extensive radiographic disease were factors independently associated with unfavorable outcomes.

CONCLUSIONS

Elderly patients with pulmonary TB are more likely to present with negative sputum smears, cavity-negative lesions, lower lung field involvement and pleural effusion on chest radiographs. The prognosis is poor for the elderly pulmonary TB patients with lower body weight, coexisting medical diseases, and extensive radiographic disease.

Aspectos clínicos da tuberculose pulmonar em idosos atendidos em hospital universitário do Rio de Janeiro, RJ, Brasil

OBJETIVOS: Avaliar as características clínicas e diagnósticas da tuberculose pulmonar (TP) em idosos. MÉTODOS: Foram comparados 117 pacientes com 60 anos de idade ou mais (idosos) e 464 pacientes entre 15 e 49 anos (não idosos), acompanhados no Instituto de Doenças do Tórax da Universidade Federal do Rio de Janeiro, de 1980 a 1996. RESULTADOS: Nos idosos, predominou história prévia de TP (OR = 2,09; IC95% = 1,26-3,45; p = 0,002) enquanto o contato intradomiciliar de TP predominou nos não idosos (OR = 0,26; IC95% = 0,10-0,66; p = 0,002). O tempo mediano para diagnóstico alcançou 90 dias nos idosos e 60 dias nos não idosos. No grupo idoso, prevaleceu a dispnéia (OR = 1,64; IC95% = 1,06-2,53; p = 0,018) e o emagrecimento (OR = 1,66; IC95% = 1,01-2,82; p = 0,047). Nos não idosos, prevaleceu a hemoptise (OR = 0,51; IC95% = 0,32-0,81; p = 0,002), a dor torácica (OR = 0,62; IC95% = 0,40-0,97; p = 0,027) e a febre (OR = 0,55; IC95% = 0,35-0,86; p = 0,006). No padrão radiológico, predominaram as infiltrações e as cavitações; porém, o acometimento bilateral foi mais freqüente nos idosos (OR = 1,76; IC95% = 1,12-2,78; p = 0.009). Não houve diferenças nas positividades do teste tuberculínico, baciloscopia e cultura de Mycobacterium tuberculosis. CONCLUSÕES: Há poucas diferenças clínicas e laboratoriais entre os grupos etários e o maior tempo de diagnóstico nos idosos deve-se à menor suspeição médica nestes pacientes.

Diagnostic and therapeutic problems of pulmonary tuberculosis in elderly patients

To identify differences in the clinical, radiologic, and microbiologic features of pulmonary tuberculosis (TB) in the young (<64 yr) and elderly (> or =65 yr), we performed a retrospective analysis of the medical charts and chest radiographs of 207 young and 119 elderly pulmonary TB patients. Hemoptysis and a febrile sense were more frequent in the young, whereas weakness, dyspnea, anorexia, and mental change were more frequent in the elderly. Elderly patients showed higher frequencies of cardiovascular and chronic lung diseases, whereas the young showed a higher proportion of underlying liver disease. In addition, chest radiography showed a significantly higher frequency of mid or lower lung involvement by TB lesions in the elderly (10.6% vs. 22.7%, p<0.05). Lesions were frequently misdiagnosed as pneumonia or lung cancer in the elderly. However, there was no difference between these two groups in terms of sputum acid-fast bacilli positivity. The elderly showed a higher frequency of adverse drug reactions (18.5% vs. 40.7%, p<0.05), and higher TB-related mortality (1.3% vs. 11.1%, p<0.05). In conclusion this study showed that young and elderly pulmonary TB patients have similar microbiologic features; however, the elderly showed higher frequencies of atypical clinical and radiologic presentations, adverse drug reactions, and higher TB-related mortality.

Impact of age and radiographic presentation on the presumptive diagnosis of pulmonary tuberculosis

We compared delay in presumptive diagnosing pulmonary tuberculosis (PTB) in elderly and younger patents, yield of diagnosis and whether the yield is influenced by the radiographic presentation, even when PTB was suspected. Time from first complaints to first consideration of PTB was determined as suspicion interval (SI) and from first consideration to diagnosis as recognition interval (RI). Presumptive diagnosis was defined as positive staining for acid-fast bacilli or presence of granulomatous lesions in pulmonary specimens. Inthe elderly and in the younger patients, the mean SI was 111.1 and 878 days respectively (P = NS), and the mean RI was 5.9 and 8.3 days, respectively (P = NS). The mean RI was longer in uncharacteristic than in characteristic radiographic findings in both elderly (8.2 and 4.6 days; P = 0.007) and younger patients (10.6 and 3.9 days; P=0.0001). A diagnosis was obtained in 89/113 elderly (79%) and in 109/138 younger (79%) patients (P=NS) and also in 59/80 (73%) patients with uncharacteristic findings and in 139/170 (82%) patients with characteristic findings (P = NS). In the latter, sputum contributed for 66% ofdiagnosis, whereas it was only 31% in patients with uncharacteristic findings (P < 0.005). In elderly patients with uncharacteristic radiographic findings, diagnosis was obtained from sputum in 41% and from other specimens in 35% (P = NS); in the younger group diagnosis was obtained from sputum in 23% and from other specimens in 48% (P < 0.05). In conclusion, there was no difference in SI and RI in elderly patients in comparison with younger patients. Uncharacteristic radiographic findings increased RI in both age groups. Age or radiographic presentation did not influence diagnosing PTB. In patients with characteristic radiographic findings, diagnosis was especially made from examination of sputum, whereas in those with uncharacteristic findings, diagnosis was more often obtained from the complementary investigation of other specimens.

Delay in diagnosis among hospitalized patients with active tuberculosis--predictors and outcomes

Delayed diagnosis of active pulmonary tuberculosis (TB) among hospitalized patients is common and believed to contribute significantly to nosocomial transmission. This study was conducted to define the occurrence, associated patient risk factors, and outcomes among patients and exposed workers of delayed diagnosis of active pulmonary TB. Among 429 patients newly diagnosed to have active pulmonary TB between June 1992 and June 1995 in 17 acute-care hospitals in four Canadian cities, initiation of appropriate treatment was delayed 1 week or more in 127 (30%). This was associated with atypical clinical and demographic patient characteristics, and after adjustment for these characteristics, with admission to hospitals with low TB admission rate of 0.2-3.3 per 10,000 admissions (odds ratio [OR]: 7.4; 95% confidence interval [CI]: 3.2,17.5) or intermediate TB admissions of 3.4-9.9/10,000 (OR: 2.3; CI: 1.6,3.2) as well as potentially preventable (late) intensive care unit admission (OR: 16.8; CI: 2.0,144) and death (OR: 3.3; CI: 1.7,6.5]). In hospitals with low TB admission rates, initially missed diagnosis, smear-positive patients undergoing bronchoscopy, late intensive care unit admission (OR: 2.3; CI: 0.1,56), and death (OR: 3.8; CI: 1.2,12.1) were more common than in hospitals with high TB admissions (> 10/ 10,000); a similar trend was seen in hospitals with intermediate TB admissions. Even after adjustment for workers' characteristics and ventilation in patients' rooms tuberculin conversions were disproportionately high in hospitals with low and intermediate TB admission rates and significantly higher in hospitals with overall TB mortality rate above 10% (OR: 2.5; CI: 1.6,3.7). In the hospitals studied, as the rate of TB admissions decreased, the likelihood of poor outcomes and risk of transmission of TB infection per hospitalized patient with TB increased. Institutional risk of TB transmission was poorly correlated with number of patients with TB and better correlated with indicators of patient care such as delayed diagnosis and treatment and overall TB-related patient mortality.

Tuberculosis is the commonest cause of pneumonia requiring hospitalization during Hajj (pilgrimage to Makkah)

The diagnosis and treatment of pneumonia in mass gathering situations is a medical challenge, requiring prompt decision making and knowledge of the aetiology. We studied cases of pneumonia admitted to two hospitals during the 1994 pilgrimage (Hajj) season to Makkah. Sixty-four patients were enrolled in the study, of which 47 (75%) were men with a mean age of 63 years (range 21-91). Nearly all were from developing countries. Diagnosis was established in 46 patients (72%) with Mycobacterium tuberculosis being the commonest causative organism (20%), followed by gram-negative bacilli (18.8%). Streptococcus pneumoniae accounted for only 10%, with Legionella pneumophilia, Mycoplasma pneumoniae, and viruses accounting each for 6%. The main finding of this study is that M. tuberculosis is a common cause of pneumonia under these unusual "extreme circumstances". Its presentation was acute and indistinguishable from pyogenic pneumonia. Thirty-one per cent of tuberculous cases had upper lobe involvement, 54% lower lobe, and 15% multi-lobar. This was similar to the radiographic features in non-tuberculous pneumonia cases. All but one patient with tuberculosis recovered following the administration of first-line anti-tuberculous drugs. The total mortality was 17%. The preponderance of M. tuberculosis and Gram-negative bacteria over S. pneumoniae may reflect the prior use of amoxycillin and the effect of exhaustion, malnutrition, and old age.

[Miliary tuberculosis - report of a case]

This is a case report of generalized miliary tuberculous infection in a 80-year old white male without the acquired immunodeficiency syndrome, whose death was caused by progressive hematogenous seeding similar to those cases of preantibiotic era. The importance of autopsy studies to uncover silent or protean infections specially in cases of cryptic or chronic hematogenous miliary tuberculosis, is emphasized.