Clinical characteristics and treatment outcomes of tuberculosis in the elderly: a case control study

Clinical, Radiological Features and Treatment Outcomes of Tuberculosis in Patients Aged 75 Years and Older

INTRODUCTION

Tuberculosis (TB) is a significant contributor to morbidity and mortality. With a progressively aging population, TB is increasingly encountered in older adults. Understanding the clinical presentation and optimal treatment strategies for TB in this population is essential.

METHOD

Clinical, radiological features, treatment, and outcome of patients aged 75 and above who were diagnosed with tuberculosis at King Abdulaziz Medical City in Riyadh in the period between January 2015 to December 2021wereevaluated retrospectively.

RESULTS

Among 92 elderly tuberculosis patients, most were male (76.1%) with a mean age of 82.5 years. Pulmonary TB was diagnosed in 52.2% of patients, Extra Pulmonary TB in 32.6%, and Disseminated TB in 15.2%. Comorbidities included Diabetes Mellitus (59.8%) and Congestive Heart Failure (41.3%). The most common presentation symptoms included cough (51.1%), fever (43.5%), dyspnea (39.1%), and weight loss (31.5%). Delay of TB diagnosis for up to 3 months was observed in 31.5% of patients. Weight loss and male gender were significant predictors of delayed diagnosis. Laboratory findings varied among TB types, with disseminated TB showing higher eosinophilia and thrombocytopenia. Completion of an initial RIPE treatment protocol was achieved in 67.6% of patients. Mortality during treatment occurred in 23.9% of patients. Pulmonary TB was associated with higher mortality compared to extrapulmonary TB (p = 0.007).

CONCLUSION

Tuberculosis is associated with high mortality in patients above the age of 75. There is still a substantial delay in TB diagnosis in the elderly. RIPE regimen is frequently changed due to side effects. Alternative regimen choices were quite variable. More studies on tuberculosis in this patient's population are needed to define the most effective therapeutic approach.

Elderly patients with tuberculosis in a low-incidence country - Clinical characteristics, inflammation and outcome

BACKGROUND

Susceptibility to respiratory infections increases with age. Diagnosing and treating tuberculosis in the elderly comes with the challenges of fewer specific symptoms and possibly more side effects of treatment. Much is unknown when it comes to tuberculosis in the elderly, especially in relation to inflammation, which may impact mortality. We, therefore, investigated a clinical cohort of elderly tuberculosis patients.

METHODS

Patients aged ≥65 years, admitted to our tuberculosis reference center between 2005 and 2021, were retrospectively included in our cohort. Sociodemographic data, clinical characteristics, laboratory results, including inflammatory markers at baseline (monocyte, neutrophil, lymphocyte count, and CRP levels), and treatment outcomes were collected. They were compared to the National Dutch TB Registry and analyzed using descriptive statistics. Survival analysis was performed using univariate Cox regression analysis and a log-rank test. Results were visualized in Kaplan-Meier curves.

RESULTS

104 elderly tuberculosis patients, mostly European, with a mean age of 75 years, were included. None were HIV-infected. Miliary tuberculosis cases were overrepresented (14 %) compared to the National Dutch TB Registry (5 % in elderly, 2 % adults). Fever occurred in 77 % (57/74), and the duration of fever decreased with age. Innate immune markers, including monocyte/lymphocyte-ratio, moderately correlated with CRP. Overall mortality was 15 %, and highest (33 %) in patients with CRP levels >100 mg/mL.

CONCLUSION

In elderly tuberculosis patients in a low-incidence setting, mortality rates are higher in comparison to younger patients. The overrepresentation of miliary tuberculosis may suggest waning immunity, with a subset of patients exhibiting strong inflammation associated with increased mortality.

Pyrazinamide in elderly people

See related article

Safety of pyrazinamide in elderly patients with tuberculosis in Japan: A nationwide cohort study

BACKGROUND AND OBJECTIVE

Pyrazinamide (PZA) is the standard first-line treatment for tuberculosis (TB); however, its safety in elderly patients has not been thoroughly investigated.

METHODS

This retrospective study used data from the Japanese Diagnosis Procedure Combination inpatient database. We identified patients who were admitted for TB between July 2010 and March 2022. Patients were categorized into HRE (isoniazid, rifampicin and ethambutol) and HREZ (isoniazid, rifampicin, ethambutol and PZA) groups. Primary outcomes included in-hospital mortality and overall adverse events (characterized by a composite of hepatotoxicity, gout attack, allergic reactions and gastrointestinal intolerance). Secondary outcomes included the length of hospital stay, 90-day readmission and use of drugs related to the primary outcome adverse events. Data were analysed using propensity score matching; we also conducted a subgroup analysis for those aged ≥75 years.

RESULTS

Among 19,930 eligible patients, 8924 received HRE and 11,006 received HREZ. Propensity score matching created 3578 matched pairs with a mean age of approximately 80 years. Compared with the HRE group, the HREZ group demonstrated a higher proportion of overall adverse events (3.1% vs. 4.7%; p < 0.001), allergic reactions (1.4% vs. 2.5%; p < 0.001) and antihistamine use (21.9% vs. 27.6%; p < 0.001). No significant differences were observed regarding in-hospital mortality, hepatotoxicity or length of hospital stay between the groups. Subgroup analysis for those aged ≥75 years showed consistent results.

CONCLUSION

Medical practitioners may consider adding PZA to an initial treatment regimen even in elderly patients with TB.

Subclinical tuberculosis: a meta-analysis of prevalence and scoping review of definitions, prevalence and clinical characteristics

BACKGROUND

This scoping review aimed to characterise definitions used to describe subclinical tuberculosis (TB), estimate the prevalence in different populations and describe the clinical characteristics and treatment outcomes in the scientific literature.

METHODS

A systematic literature search was conducted using PubMed. We included studies published in English between January 1990 and August 2022 that defined "subclinical" or "asymptomatic" pulmonary TB disease, regardless of age, HIV status and comorbidities. We estimated the weighted pooled proportions of subclinical TB using a random-effects model by World Health Organization reported TB incidence, populations and settings. We also pooled the proportion of subclinical TB according to definitions described in published prevalence surveys.

RESULTS

We identified 29 prevalence surveys and 71 other studies. Prevalence survey data (2002-2022) using "absence of cough of any duration" criteria reported higher subclinical TB prevalence than those using the stricter "completely asymptomatic" threshold. Prevalence estimates overlap in studies using other symptoms and cough duration. Subclinical TB in studies was commonly defined as asymptomatic TB disease. Higher prevalence was reported in high TB burden areas, community settings and immunocompetent populations. People with subclinical TB showed less extensive radiographic abnormalities, higher treatment success rates and lower mortality, although studies were few.

CONCLUSION

A substantial proportion of TB is subclinical. However, prevalence estimates were highly heterogeneous between settings. Most published studies incompletely characterised the phenotype of people with subclinical TB. Standardised definitions and diagnostic criteria are needed to characterise this phenotype. Further research is required to enhance case finding, screening, diagnostics and treatment options for subclinical TB.

Tuberculosis in older adults: challenges and best practices in the Western Pacific Region

The Western Pacific has one of the fastest-growing older adult populations globally, and tuberculosis (TB) remains one of the foremost infectious causes of disease and death in the region. Older adults are at higher risk of TB due to immunosenescence, comorbidities, and increased institutionalisation. Atypical symptoms and reduced access to health services may delay care-seeking and TB diagnosis, while co-morbidity and increased risk of adverse drug reactions complicate TB treatment. Post-TB sequelae and socioeconomic challenges may decrease the quality of life after TB treatment completion. Despite their high disease burden and special challenges, there is a lack of regionally coordinated policies and guidelines to manage TB among older adults. Routine TB screening at aged-care facilities, age-friendly infrastructure and services, awareness of atypical TB features, integration of TB and non-communicable diseases services, and person-centred approaches to treatment support could improve TB management among older adults. Addressing these challenges and adopting the best practices identified should inform policy formulation and implementation.

Funding

This project was funded by 1) the World Health Organization Regional Office for the Western Pacific, with financial contributions from the Government of the Republic of Korea through the Korean Disease Control and Prevention Agency and the Government of Japan through the Ministry of Health, Labour and Welfare, and 2) NUS Start-up Grant. The funders had no role in the paper design, collection, analysis, and interpretation of data and in writing of the paper.

Deep learning based CT images automatic analysis model for active/non-active pulmonary tuberculosis differential diagnosis

Active pulmonary tuberculosis (ATB), which is more infectious and has a higher mortality rate compared with non-active pulmonary tuberculosis (non-ATB), needs to be diagnosed accurately and timely to prevent the tuberculosis from spreading and causing deaths. However, traditional differential diagnosis methods of active pulmonary tuberculosis involve bacteriological testing, sputum culturing and radiological images reading, which is time consuming and labour intensive. Therefore, an artificial intelligence model for ATB differential diagnosis would offer great assistance in clinical practice. In this study, computer tomography (CT) scans images and corresponding clinical information of 1160 ATB patients and 1131 patients with non-ATB were collected and divided into training, validation, and testing sets. A 3-dimension (3D) Nested UNet model was utilized to delineate lung field regions in the CT images, and three different pre-trained deep learning models including 3D VGG-16, 3D EfficientNet and 3D ResNet-50 were used for classification and differential diagnosis task. We also collected an external testing set with 100 ATB cases and 100 Non-ATB cases for further validation of the model. In the internal and external testing set, the 3D ResNet-50 model outperformed other models, reaching an AUC of 0.961 and 0.946, respectively. The 3D ResNet-50 model reached even higher levels of diagnostic accuracy than experienced radiologists, while the CT images reading and diagnosing speed was 10 times faster than human experts. The model was also capable of visualizing clinician interpretable lung lesion regions important for differential diagnosis, making it a powerful tool assisting ATB diagnosis. In conclusion, we developed an auxiliary tool to differentiate active and non-active pulmonary tuberculosis, which would have broad prospects in the bedside.

Challenges in diagnosis and treatment of tuberculosis in elderly

Tuberculosis (TB) is a major infectious disease worldwide. Early diagnosis and prompt treatment reduces the transmission, morbidity and mortality in tuberculosis. Elderly (age >65 years) have many risk factors to develop tuberculosis. Recent survey in India showed incidence of TB higher in elderly. They may not have classical symptoms, clinical and radiological signs of TB which can lead to delayed diagnosis or misdiagnosis. In addition, elderly have many comorbid and coexisting diseases which make diagnosis and treatment of TB challenging. Comorbidities, poor general health status and other medications may lead to increased drug adverse reactions and poor adherence to treatment in elderly. Hence special emphasis should be given to elderly for early diagnosis and treatment. Elderly with multiple comorbidities require individualized approach for better outcome.

BTS clinical statement for the diagnosis and management of ocular tuberculosis

The BTS clinical statement for the diagnosis and management of ocular tuberculosis (TB) draws on the expertise of both TB and and ophthalmic specialists to outline the current understanding of disease pathogenesis, diagnosis and management in adults. Published literature lacks high-quality evidence to inform clinical practice and there is also a paucity of data from animal models to elucidate mechanisms of disease. However, in order to improve and standardise patient care, this statement provides consensus points with the currently available data and agreed best practice.

Characteristics of tuberculosis-related deaths and risk factors: a retrospective cohort study in Samsun province of Turkey

OBJECTIVES

Tuberculosis (TB) remains one of the top ten leading causes of death worldwide despite effective therapy. The present study aims to examine the characteristics of TB-related deaths in Samsun Province and to determine the risk factors.

METHODS

In this retrospective registry-based cohort study, the medical records of patients registered with Samsun Tuberculosis Control Dispensary between January 1, 2018, and December 31, 2019, were retrospectively reviewed. The Cox proportional-hazards model was used to determine the factors associated with the risk of death in patients with TB.

RESULTS

The treatment outcomes of a total of 382 patients were reviewed. It was found that the treatment was successful in 346 patients (90.6%), and 31 patients (8.1%) died before or during TB therapy. The median survival time of patients who died during the therapy was 1.86 months (95% CI= 0.07 - 5.17 months), and more than 50% (13/25) of the deaths occurred in the first two months of the treatment. Age above 70 years (HR 15.06 (3.33-67.95)), male gender (HR 2.74 (1.02-7.33)), pulmonary TB (HR 2.92 (1.002-8.52)), multidrug-resistant (MDR) tuberculosis (HR 1.69 (1.22-12.75)), and a delay in the treatment of more than ten days (HR 2.71 (1.22-6.04)) were identified as risk factors associated with mortality in TB patients (p<0.05).

CONCLUSION

The majority of deaths in our cohort occurred within the first two months after starting the treatment. Advanced age, male sex, a new diagnosis of TB, pulmonary TB, MDR-TB, and a treatment delay of more than ten days after diagnosis increased the risk for mortality during antituberculosis treatment.

Tuberculosis in the Elderly

The tuberculosis (TB) epidemic is most prevalent in the elderly, and there is a progressive increase in the notification rate with age. Most cases of TB in the elderly are linked to the reactivation of lesions that have remained dormant. The awakening of these lesions is attributable to changes in the immune system related to senescence. The mortality rate from tuberculosis remains higher in elderly patients. Symptoms of active TB are nonspecific and less pronounced in the elderly. Diagnostic difficulties in the elderly are common in many diseases but it is important to use all possible techniques to make a microbiological diagnosis. Recognising frailty to prevent loss of independence is a major challenge in dealing with the therapeutic aspects of elderly patients. Several studies report contrasting data about poorer tolerance of TB drugs in this population. Adherence to antituberculosis treatment is a fundamental issue for the outcome of treatment. Decreased completeness of treatment was shown in older people as well as a higher risk of treatment failure.

Clinical spectrum and outcomes of geriatric tuberculosis emergencies in North India

OBJECTIVES:

Despite the acute and life-threatening repercussions that tuberculosis (TB) may have on the burgeoning older population in endemic countries like India, the spectrum of geriatric TB emergencies is not adequately understood.

METHODS:

We performed a prospective observational study at the emergency department of an academic hospital in north India between January 2019 and June 2020, investigating the clinical and laboratory features and outcomes of active TB in older patients aged 60 years and above.

RESULTS:

Out of 71 geriatric TB emergencies, central nervous system disease predominated (n = 41, 57.7%), followed by pulmonary (n = 16, 22.5%), pleural TB (n = 8, 11.3%), and multisite involvement (n = 6, 8.4%). Nearly 71.8% were male, and 77.4% belonged to low socioeconomic status (lower-middle or lower class). Usual predisposing factors were tobacco smoking (38.0%), chronic alcohol use (27.0%), and diabetes mellitus (23.9%). Atypical features were more frequent with extrapulmonary TB. Only 28.2% were microbiologically confirmed cases, and rifampicin resistance was seen in only one case. The mortality rate was considerably high (24.0%), highest with pulmonary TB (37.0%).

CONCLUSION:

Older patients with TB emergencies have atypical presentations, diagnostic difficulties, and high mortality.

Hypersensitivity reactions to multiple anti-tuberculosis drugs

Objective

This study aimed to evaluate hypersensitivity reactions to anti-tuberculosis (TB) drugs.

Methods

We retrospectively compared the clinical manifestations and treatment outcomes of single and multiple drug hypersensitivity reactions (DHRs).

Results

Twenty-eight patients were diagnosed with anti-TB DHRs using oral drug provocation tests. Of these 28 patients, 17 patients (60.7%) had DHRs to a single drug and 11 (39.3%) had multiple DHRs. The median age of patients was 57.5 years (interquartile range [IQR], 39.2–73.2). Of the total patients, 18 patients (64.3%) were men. The median number of anti-TB drugs causing multiple DHRs was 2.0 (IQR 2.0–3.0). Rifampin was the most common drug that caused DHRs in both the single and multiple DHR groups (n = 8 [47.1%] and n = 9 [52.9%], respectively). The treatment success rate was lower in the multiple DHR group than in the single DHR group; however, the difference was not statistically significant (81.8% vs. 94.1%; P = 0.543).

Conclusions

Multiple anti-TB DHRs were common in all patients who experienced DHRs, and rifampin was the most common causative drug. The treatment outcomes appeared to be poorer in patients with multiple DHRs than in those with single DHRs.

Assessment of Strategies and Epidemiological Characteristics of Tuberculosis in Henan Province, China: Observational Study

Background

In 2005, China established an internet-based Tuberculosis Information Management System (TBIMS) to monitor changes in tuberculosis (TB). Many scholars have conducted epidemiological research using TBIMS; however, few studies assessing control strategies have been performed based on this platform data. Henan province is a high TB incidence area in China where, in addition to following the nationwide TB strategies, a series of local intervention combinations have been implemented.

Objective

Our study aims to evaluate the impact of nationwide TB intervention combinations on epidemiological changes and determine whether Henan province can achieve the World Health Organization’s (WHO) goal of reducing TB incidence by 50% and TB mortality by 75% by the year 2025.

Methods

We used descriptive statistical methods to show the spatial and temporal distribution of pulmonary tuberculosis (PTB) reported to the TBIMS database from 2005 to 2018, and logistic regression analysis was performed to identify the risk factors of bacteriological-positive TB. The dynamic compartmental model and Bayesian melding approach was adopted to estimate the burden of TB under the impact of different TB control policies.

Results

In total, 976,526 PTB cases were notified to the TBIMS in Henan in a period of 14 years. Although the overall incidence of PTB declined from 91.4/10⁵ to 58.5/10⁵, and the overall incidence of bacteriological-positive PTB declined from 44.5/10⁵ to 14.7/10⁵, the WHO’s 2025 goal could not be met. The distribution of high incidence and poverty-stricken counties were basically overlapped. Men, farmers and herdsmen (in rural areas), and subjects aged ≥60 years were more likely to develop bacteriological-positive PTB. The increasing treatment success for drug-susceptible tuberculosis and multidrug-resistant tuberculosis has not provided the desired reduction in incidence and mortality.

Conclusions

To achieve the targeted goal, while improving the cure rate of TB, new active (rather than passive) detection and intervention strategies should be formulated based on epidemiological characteristics in Henan province.

Safety of Pyrazinamide for the Treatment of Tuberculosis in Older Patients Over 75 Years of Age: A Retrospective Monocentric Cohort Study

OBJECTIVES

Pyrazinamide (PZA) has a controversial safety profile in older patients. We aimed to assess the frequency and risk factors for adverse drug reactions (ADRs) in patients over 75 years of age treated for tuberculosis with or without PZA.

METHODS

We conducted a retrospective monocentric study including patients aged over 75 years treated for active tuberculosis between 2008 and 2018. The frequency, type, seriousness, and causality assessment of ADRs to anti-tuberculosis treatment were compared between patients receiving PZA or not. Risk factors for ADRs were investigated using univariable and multivariable analyses by logistic regression.

RESULTS

Among the 110 patients included, 54 (49.1%) received PZA (group 1) and 56 (50.9%) did not (group 2). ADRs to anti-tuberculosis drugs occurred in 31 patients (57.4%) in groups 1 and 15 (26.8%) in group 2 (p = 0.003). PZA-related ADRs occurred in 40.7% of exposed patients. Frequency of renal ADRs was higher in group 1 (9.3% vs 0%; p = 0.026). Rates of hepatic (18.5% vs 12.5%; p = 0.38), digestive (22.2% vs 8.9%; p = 0.054), and allergic (14.8% vs 5.4%; p = 0.12) ADRs were numerically higher in group 1 although the differences were not statistically significant. Serious ADRs occurred more frequently in group 1 (24.1% vs 8.9%; p = 0.03). The use of PZA was the only independent risk factor for ADRs to anti-tuberculosis drugs (odds ratio 3.75, 95% CI 1.5-9.6; p = 0.0056). No risk factors for PZA-related ADRs were identified.

CONCLUSION

In older French patients, the use of PZA was associated with more frequent ADRs to anti-tuberculosis drugs.

Active Pulmonary Tuberculosis in Elderly Patients: A 2016-2019 Retrospective Analysis from an Italian Referral Hospital

Tuberculosis (TB) in the elderly (>65 years old) has increasingly become a global health problem. It has long been recognized that older people are vulnerable to developing tuberculosis. We retrospectively evaluated data from patients older than 65 years diagnosed with pulmonary TB admitted to the National Institute for Infectious Diseases L. Spallanzani, Rome, Italy, from 1 January 2016 to 31 December 2019. One hundred and six consecutive patients were diagnosed with pulmonary TB and 68% reported at least one comorbidity and 44% at least one of the TB risk-factors. Out of the 26 elderly patients who reported an adverse event, having risk factors for TB (O.R. (Odds Ratios) = 1.45; 95% CI 1.12-3.65) and the presence of cavities on Chest X-rays (O.R. = 1.42; 95% CI 1.08-2.73) resulted in being more likely to be associated with adverse events in elderly patients. Having weight loss (O.R. = 1.31; 95% CI 1.08-1.55) and dyspnea (O.R. = 1.23; 95% CI 1.13-1.41) resulted in being significant predictors of unsuccessful treatment outcome in elderly patients. Older people with TB represent a vulnerable group, with high mortality rate, with a challenging diagnosis. Hospitalizations in tertiary referral hospital with clinical expertise in TB management can be useful to improve the outcome of these fragile patients.

The high incidence of severe adverse events due to pyrazinamide in elderly patients with tuberculosis

Background

Pyrazinamide (PZA) is a common drug that causes serious adverse events (SAEs). The aim of this study was to determine the incidence of and risk factors for SAEs due to PZA during first-line anti-tuberculosis treatment.

Methods

The medical records of patients with tuberculosis (TB) treated with PZA-containing regimens including first-line drugs—ethambutol, rifampicin, and isoniazid—from January 2003 to June 2016 were reviewed. SAEs were defined as side effects that led to drug discontinuation. The causative drug was determined based on the disappearance of the SAEs upon drug withdrawal and/or the recurrence of the same SAEs with re-challenge.

Results

Of 2,478 patients with TB, 16.4% experienced SAEs. The incidence of SAEs increased significantly as age increased, except with rifampin. PZA accounted for most SAEs (55.8%). Hepatotoxicity was the most common SAE due to PZA (44.5%), followed by gastrointestinal (GI) intolerance (23.8%). The risk of SAEs due to PZA increased significantly as age increased, when sex and comorbidities were adjusted (odds ratio, 1.013; 95% confidence interval, 1.004–1.023; P = 0.007). In the subgroup analysis, older age was an independent risk factor for GI intolerance but not for hepatotoxicity.

Conclusion

PZA was the most common drug associated with SAEs among the first-line anti-TB drugs, and old age was an independent factor for SAE occurrence. This study suggests that the early recognition of whether the causative agent is PZA may improve effective treatment compliance, particularly in elderly patients.

Radiological significance of high-resolution computed tomography for elderly pulmonary tuberculosis patients - an analysis with culture test

Purpose

Pulmonary tuberculosis (PTB) is one of the major health problems in the elderly population, causing significant morbidity and mortality. The aim of this study is to evaluate the significance of the high-resolution computed tomography (HRCT) modality for the diagnosis of PTB, in comparison to culture test.

Material and methods

Thoracic HRCT images of the study population, comprising 124 patients clinically suspected for PTB with smear and culture reports, were analysed for sensitivity and specificity of the HRCT test. Features of active PTB were centrilobular nodules, ‘tree-in-bud’ pattern densities, macro-nodules, consolidations, cavitary lesions, ground-glass opacities, and miliary nodules.

Results

Among the study population, 108 cases presented HRCT features of active PTB and the remaining cases were negative but had presented a few features mimicking PTB. As inferred from positive culture test results, 106 cases had active PTB, the remaining cases were culture negative for PTB. False-positive (FP) or ‘type I error’ cases, and false-negative (FN) or ‘type II error’ cases were ascertained by Bayes’ theorem. Sensitivity (true positive rate) and specificity (true negative rate) of HRCT test were 0.8125 and 0.8571, respectively.

Conclusions

For proper diagnosis the predictive capability, as two values of ‘a posteriori probability’, was computed; the mean value of ‘a posteriori probability’ for HRCT was 0.6358. When its culture test was positive, the HRCT test was 69.56-92.85% efficient in ascertaining positive results with a sample; on the other hand, when its culture test was negative it was 66.66-100% efficient for a negative result. Thus, the HRCT test is considerably dependable.

Central nervous system tuberculoma with miliary tuberculosis in the elderly

The aging phenomenon of tuberculosis (TB) patients is recognized all over the world, but no country is as prominent as Japan. Central nervous system (CNS) TB includes clinical entities: tuberculous meningitis, intracranial tuberculoma, and clinical features of CNS TB in the elderly may be atypical, non-specific, and confused with concomitant age-related diseases. Atypical clinical manifestations of TB in older persons can result in delay in diagnosis and initiation of treatment. A 91-year-old woman was brought to our emergency department after her family noted her altered mental status. Chest computed tomography confirmed miliary opacities. The cerebrospinal fluid (CSF) analysis showed elevated protein level, low glucose level, and a lymphocytic pleocytosis. Brain magnetic resonance imaging (MRI) showed multiple well‑defined enhancing lesions in the cerebral and cerebellar hemispheres and the pons, suggestive of tuberculomas. Smear, culture, and polymerase chain reaction (PCR) tests confirmed Mycobacterium tuberculosis in the sputum and aspirate. Based on the CSF and brain MRI findings and the sputum microbiology results indicating the presence of M. tuberculosis in the sputum and gastric aspirate, the patient was diagnosed with CNS tuberculoma. The onset of TB is mainly associated with decreased immunity; however, several other factors such as comorbidities, decreased activity, dysphagia, and malnutrition, which influence one another, also influence the development of TB in the elderly. Because the mortality rate of TB increases rapidly with age, reaching approximately 30 % among the elderly, early diagnosis is critical.

The ongoing challenge of Pulmonary Tuberculosis in Southern Tunisia: A review of a 22-year period

BACKGROUND

Despite the wide use of anti-tuberculosis drugs, pulmonary tuberculosis (PTB) remains one of the most important causes of mortality and morbidity, particularly in developing countries. Therefore, combining clinical and epidemiological approach would be of a great benefit. Our study aimed to describe the epidemiological and clinical specificities of PTB and its recent chronological trends.

METHODS

We conducted a retrospective study of all PTB new cases of any age diagnosed between 1995 and 2016 in Southern Tunisia. We applied the direct method of age-standardization using the World Standard Population to compute the age standardized incidence rate (ASIR) and the age standardized mortality rate (ASMR) per 100 000 inhabitants.

RESULTS

We recorded 1121 new cases with PTB among 2771 new cases of tuberculosis (40.5%). The ASIR of PTB was 5.3/100 000 inhabitants/year and didn't change over the study period (rho=0.3; P=0.2). Patients with PTB were mainly aged between 15 and 59 years (n=861; 76.8%) and came from urban areas (n=600; 55%). The median duration of treatment was 7.6 months (IQR=[6-8 months]). Successful outcome was notified in 1075 cases (95.9%). Forty-one patients died yielding an ASMR of 0.18/100 000 inhabitants/year. Factors statistically associated with unsuccessful outcome included age≥60 years (OR=5; P<0.001) and shorter treatment duration (6.15 months vs 7.76 months; P<0.001).

CONCLUSION

In contrast to the decline in the global PTB incidence reported worldwide and in the neighboring countries, our study revealed no significant change in the PTB rates from 1995 to 2016. Therefore, tools and strategies used to manage PTB should be strengthened by a substantial effort in both basic science and epidemiology to have better incidence curves.

Clinical characteristics of elderly pulmonary tuberculosis in an acute-care general hospital in Tokyo, Japan: A 12-year retrospective study

OBJECTIVE

A significant feature of tuberculosis (TB) in Japan is the fact that a high proportion of cases belong to the elderly population. Furthermore, previous reports have pointed out the delayed diagnosis of pulmonary TB in acute-care settings. We aimed to examine the clinical characteristics of pulmonary TB patients in an acute-care general hospital, particularly focusing on the elderly population.

METHODS

We retrospectively reviewed the medical records of patients with pulmonary TB who presented at our institution between May 2005 and December 2016. We described the overall clinical characteristics of these patients and compared them according to age.

RESULTS

Overall, 289 patients were eligible for the analysis, with a median age of 58 [42-73] years, and 29.4% being older than 70 years. Among the elderly patients, 42.4% were characterized by atypical presentation.

CONCLUSION

Our findings suggest that the elderly population tends to present as atypical cases lacking respiratory complaints, thereby being at a risk of misdiagnosis.

Unsuccessful treatment in pulmonary tuberculosis: factors and a consequent predictive model

Background

Cure is particularly valuable in pulmonary cases (PTB), as unsuccessful treatment fuels incidence and resistance to antibiotics. This study aims to identify individual factors of PTB unsuccessful treatment in Portugal and to develop a consequent predictive model.

Methods

Using the Portuguese TB surveillance database (SVIG-TB), PTB cases older than 15 years notified from 2000 to 2012 in Continental Portugal were analyzed. Unsuccessful treatment included the WHO categories (failure, default, death and transferred out). Based on a literature review, predictors involved sociodemographic, behavioral, disease-related and treatment-related factors. Binary logistic regression was used to estimate unsuccessful treatment factors and to develop the predictive risk model.

Results

The unsuccessful outcome rate in PTB patients was of 11.9%. The predictive model included the following factors: TB/HIV co-infection (OR 4.93), age over 64 years (OR 4.37), IV drugs abuse (OR 2.29), other diseases (excluding HIV and Diabetes, OR 2.09) and retreatment (OR 1.44), displaying a rather good validity.

Conclusion

The overall treatment unsuccessful treatment rate in PTB patients complies with the 85% WHO success threshold. The predictive model of unsuccessful treatment proved well. Nomogram representation allows an early, intuitive identification of PTB patients at increased risk. The model is liable to widespread use as a prognostic tool.

Treatment outcomes and factors affecting treatment outcomes of new patients with tuberculosis in Busan, South Korea: a retrospective study of a citywide registry, 2014-2015

Background

This study investigated the treatment outcomes, and factors affecting the outcomes, of new tuberculosis (TB) patients in Busan, South Korea.

Methods

We retrospectively analysed the citywide TB registry data (collected for the Korean National TB Surveillance System) of new TB patients registered in Busan from January 2014 to December 2015.

Results

A total of 4732 patients were included in this study (mean age, 52.5 ± 19.9 years; 58.4% male). The overall treatment success rate was 83.9% (cured, 20.2%; completed, 63.7%); 8.0% of patients died, and 3.6% were lost to follow-up. In multivariate analyses, a higher rate of loss to follow-up was associated with foreign nationality, registered as TB-positive at least twice, and being in Q4 (fourth quintile) or Q5 (fifth quintile) of the regional deprivation index. Conversely, a lower rate of loss to follow-up was associated with female gender, smear-positive for pulmonary TB (PTB), and the treatment outcome being reported by a public health centre. Higher mortality was associated with old age (≥ 75 years), smear-positive PTB, treatment outcome being reported by the hospital, and being registered as TB-positive twice. Lower mortality was associated with female gender, treatment outcome being reported by a public health centre or clinic, and Q5 of the regional deprivation index.

Conclusions

Treatment outcomes of new TB patients were sub-optimal in Busan. TB control programs should maintain close monitoring and provide greater socioeconomic support to patients at high risk of poor treatment outcomes.

[Tuberculosis in older persons in African setting: Epidemiological, diagnostic and evolutive features]

OBJECTIVE

To determine the epidemiological, diagnostic and evolutives features of tuberculosis (TB) in older subjects in Benin.

PATIENTS AND METHODS

This was a retrospective cohort study of adults TB patients (age≥15 years) who were notified at all the Basic Management Units (BMU) in Benin from January 1st, 2013 to December 31st. Older subjects (age≥60 years) were compared to those less than 60 years named young subjects. The threshold of significance was set at 5%.

RESULTS

The analysis was carried out on 6531 cases adults cases notified during the period. 601 (9.2%) were 60 years old or above. The case notification rate (CNR) in elders was more than twice the CNR in young people (68 cases vs. 31 cases per 100,000 population). Older subjects were less often infected with HIV (9.3%) than young's (16.7%), P<0.0001. In new bacteriologically confirmed pulmonary TB negative for HIV, unfavorable treatment outcomes were more frequent in older subjects than in young subjects with more deaths (7.5% vs. 3.0%). On the other hand, in bacteriological confirmed TB seropositive for HIV and all the other cases, treatment outcomes were comparable between the two groups.

CONCLUSION

The high CNR and the high death rate in older subjects should plead for a specific care for an adapted management of TB case in this group.

Clinical Characteristics of Nursing- and Healthcare-Associated Tuberculosis

Tuberculosis remains a serious health problem worldwide. Patients with tuberculosis who also require nursing care due to aging and underlying diseases are considered to have a high mortality rate; however, there are few studies describing detailed examinations of such disease conditions. Objective: The present study was conducted to investigate differences in clinical features of elderly tuberculosis patients according to the levels of nursing and healthcare required. Design: The study participants included 146 elderly (≥65 years) patients diagnosed with active tuberculosis among patients hospitalized with tuberculosis at a single center. The patients were classified into two groups: a nursing- and healthcare-associated tuberculosis group (n = 71) and a community-acquired tuberculosis group (n = 75). Results: The nursing- and healthcare-associated tuberculosis patients were older and had a higher frequency of comorbidities compared with the community-acquired tuberculosis group. Patients in the nursing- and healthcare-associated tuberculosis group had markedly lower levels of serum albumin and hemoglobin, and higher levels of C-reactive protein. The rate of in-hospital death was significantly higher in the nursing- and healthcare-associated tuberculosis group. This was attributed to malnutrition and comorbid conditions rather than the severity of tuberculosis. Conclusion: The prognosis was poor in elderly tuberculosis patients receiving nursing and healthcare.

Epidemiological, clinical and mechanistic perspectives of tuberculosis in older people

With the ageing population globally, tuberculosis (TB) in older people becomes a major clinical and public health challenge. In many Asian countries, especially those located in the eastern and southeastern parts of the continent, geriatric TB is a significant problem. TB in the older patients is more difficult to diagnose in the early course of disease, and has poorer treatment outcomes, largely as increased failure and death. More drug-induced adverse reactions are also experienced by this population during TB therapy. Oxidative stress and mitochondrial dysfunction are now well recognized to be associated with the ageing process, and it is likely that the cellular and molecular perturbations interact inextricably with the immunological dysfunction biophysiologically inherent to ageing. These underlying mechanistic bases putatively contribute to the development of TB in the geriatric population and worsen the disease outcomes, especially when the TB is compounded by co-morbid conditions such as smoking and diabetes mellitus. Unravelling these mechanisms further would yield knowledge that might potentially help to prevent reactivated TB in older people, and also to better manage the established disease with drug regimens and other new therapeutic strategies. In addition, addressing the social elements associated with geriatric TB is also imperative in the relief of individual patient suffering and improvement of overall disease control.

Using genotyping to delineate tuberculosis transmission in long-term care facilities: single facility 4-year experience

Background

Residents in long-term care facilities (LTCFs) are vulnerable to tuberculosis (TB) transmission; however, to delineate possible routes of TB transmission in LTCFs is difficult. This study aimed to address the use of regular genotyping surveillance to delineate TB transmission in LTCFs.

Methods

All of Mycobacterium tuberculosis isolates in the reported 620-bed LTCF between July 2011 and August 2015 were genotyped, and we retrospectively compared epidemiological data and genotyping results.

Results

A total of 42 subjects were diagnosed with culture-positive pulmonary TB infection during the 4-year period. Their median age was 76.5 years, and 64.3% (27/42) of them were male. Genotyping identified 5 clustered TB infections involving 76.2% (32/42) of all TB subjects. In a multivariate logistic regression model adjusted for age, sex, chronic obstructive pulmonary disease, and body mass index, subjects with clustered TB infection were less likely to be Activities of Daily Living (ADL)-dependence (adjOR 0.073, 95% CI 0.007–0.758) when compared with subjects having individual TB infections. Prolonged surveillance is essential given that the median interval to diagnose secondary subjects was 673 days. Finally, only 63.0% (17/27) of the 27 secondary TB subjects in this study had contact history with index subject in the same ward.

Conclusions

In conclusion, possible routes of TB transmission in a complex TB outbreak at LTCFs might be delineated by routine genotyping surveillance and regular health check-up.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2526-2) contains supplementary material, which is available to authorized users.

Does tuberculosis threaten our ageing populations?

Background

The global population is ageing quickly and our understanding of age-related changes in the immune system suggest that the elderly will have less immunological protection from active tuberculosis (TB).

Discussion

Ongoing global surveillance of TB notifications shows increasing age of patients with active TB. This effect of age is compounded by changes to clinical manifestations of disease, confounding of diagnostic tests and increased rates of adverse reactions to antimicrobial treatment of TB. Future epidemiological surveillance, development of diagnostic tests and trials of treatment shortening should all include a focus on ageing people.

Summary

More detailed surveillance of TB notifications in elderly people should be undertaken and carefully evaluated. Risk stratification will help target care for those in greatest need, particularly those with comorbidities or on immunosuppressive therapies. Novel diagnostics and treatment regimes should be designed specifically to be used in this cohort.

A pulmonary tuberculosis outbreak in a long-term care facility

In long-term care facilities (LTCFs), the elderly are apt to be infected because those with latent tuberculosis infections (LTBIs) are at an increased risk for reactivation and post-primary TB disease. We report an outbreak of TB in staff and residents in a LTCF. An outbreak investigation was conducted after two TB cases were reported from the LTCF. A tuberculin skin test (TST), bacteriological examination and chest radiograph were administered to all facility staff and residents. An outbreak is defined as at least two epidemiologically linked cases that have identical Mycobacterium tuberculosis genotype isolates. This outbreak infected eight residents and one staff member, who were confirmed to have TB in a LTCF between September 2011 and October 2012. Based on the Becker method, the latent and infectious periods were estimated at 223·6 and 55·9 days. Two initial TST-negative resident contacts were diagnosed as TB cases through comprehensive TB screening. Observing elderly people who have a negative TST after TB screening appears to be necessary, given the long latent period for controlling a TB outbreak in a LTCF. It is important to consider providing LTBI treatment for elderly contacts.

Comparison of clinical characteristics of tuberculosis between two age groups at an Italian Tertiary Hospital

Differences in clinical characteristics and outcome between elderly (>60 years) and younger (18-59 years) tuberculosis (TB) patients were retrospectively evaluated. Alcohol abuse, radiological evidence of cavitation, and cough at presentation were more frequent among younger patients. Older patients were more likely to have comorbidities, disseminated TB, longer duration of symptoms and higher TB-related mortality (19 vs 0%). Very old patients (≥80 years) showed increased liver toxicity and hospital acquired infections compared to patients aged 60-79 years.

Risk factors for death during pulmonary tuberculosis treatment in Korea: a multicenter retrospective cohort study

The data regarding risk factors for death during tuberculosis (TB) treatment are inconsistent, and few studies examined this issue in Korea. The purpose of this study was to evaluate baseline prognostic factors for death during treatment of adult patients with pulmonary TB in Korea. A multicenter retrospective cohort study of 2,481 patients who received TB treatment at eight hospitals from January 2009 to December 2010 was performed. Successful treatment included cure (1,129, 45.5%) and treatment completion (1,204, 48.5%) in 2,333 patients (94.0%). Unsuccessful treatment included death (85, 3.4%) and treatment failure (63, 2.5%) occurred in 148 patients (6.0%). In multivariate analysis, male sex, anemia, dyspnea, chronic heart disease, malignancy, and intensive care unit (ICU) admission were significant risk factors for death during TB treatment. Therefore, male sex, anemia, dyspnea, chronic heart disease, malignancy, and ICU admission could be baseline prognostic factors for death during treatment of adult patients with pulmonary TB in Korea.

Diagnosis of pulmonary tuberculosis and nontuberculous mycobacterial lung disease in Korea

The recovery of nontuberculous mycobacteria (NTM) from respiratory specimens and the number of patients with NTM lung disease have been rapidly increasing in Korea. An early differential diagnosis of NTM lung disease from pulmonary tuberculosis (TB) is important, as the therapeutic regimen differs from that of pulmonary TB, and it is not necessary to track the contacts of patients with NTM lung disease. However, differentiating NTM lung disease from pulmonary TB remains difficult, because the clinical presentations of the two diseases are similar and a definite diagnosis of NTM lung disease based on sputum culture takes time. This review focuses on the changing epidemiology, clinical and radiographic manifestation, and laboratory diagnosis of pulmonary TB and NTM lung disease in Korea.

Profile and response to anti-tuberculosis treatment among elderly tuberculosis patients treated under the TB Control programme in South India

INTRODUCTION

The demographic transition in India has resulted in an increase in the elderly population. There is limited data on the profile of elderly tuberculosis (TB) patients and their treatment outcomes in India.

OBJECTIVE

To compare the clinical profile, presentation and response to anti-TB treatment among elderly (≥ 60 yrs) and younger (15-59 yrs) TB patients treated under the Revised National TB Control programme.

METHODOLOGY

Retrospective cohort analysis of TB patients treated from May 1999 to December 2004 in one Tuberculosis Unit of Tiruvallur district, South India.

RESULTS

Records of 865 elderly and 4343 younger TB patients were examined: elderly were more likely to be male (84% vs. 71%), smokers (46% vs.37%), illiterate (63% vs. 45%), identified by active case finding through survey (19% vs. 11%), have pulmonary TB (96% vs. 91%) and initial smear negative disease (46% vs. 36%) compared to younger (for all p<0.001). Among a total of 352 elderly and 1933 younger new smear positive pulmonary TB, the elderly had higher loss to follow-up (15% vs. 11%; p = 0.03) and death rates (9% vs. 4%; p<0.001). Mycobacterium tuberculosis susceptibility to first line anti-TB drugs did not differ (elderly 87% vs. younger 84%) (p = 0.20). Side effects related to anti-TB drugs were reported by a higher proportion of elderly patients (63% vs. 54%) (p = 0.005). Previously treated patients had similar treatment outcomes in both the groups.

CONCLUSION

Elderly TB patients are less likely to have smear positive disease. Newly diagnosed elderly TB patients are more likely to be lost to follow-up or die and report drug side effects. Suitable interventions need to be developed for effective management and better treatment outcomes of TB in the elderly.

Clinical and radiographic manifestations and treatment outcome of pulmonary tuberculosis in the elderly in khuzestan, southwest iran

BACKGROUND

Presentation of pulmonary tuberculosis (PTB) in the elderly is expected to be different from that in younger patients because of the debilitating factors and comorbidities. This issue should be considered in the national tuberculosis programs of countries. The purpose of this study was to evaluate the differences in the clinical and radiographic manifestations and treatment outcomes of PTB between the elderly and young patients.

MATERIALS AND METHODS

This study was conducted as part of a mega project on tuberculosis by the Infectious and Tropical Diseases Research Centre affiliated to Ahvaz Jundishapur University of Medical Sciences. We retrospectively analyzed the medical records of 2,080 relatively young (18-64 years old at the time of diagnosis) and 346 elderly (≥65 years) PTB patients, who had been recently diagnosed and treated in the TB unit of Khuzestan Health Center from 2005 to 2010.

RESULTS

Dyspnea and hemoptysis were the most common symptoms and the frequency of positive sputum smear -AFB was lower in the elderly PTB patients. On chest X-ray, elderly patients were less likely to have cavitation in comparison with younger patients. The frequency of favourable treatment outcome in the elderly was significantly lower than that in younger patients (64% vs. 77%, P = 0.003).

CONCLUSION

Dyspnea, weight loss and hemoptysis were more common in the elderly PTB patients. Chest X-ray showed less frequent typical findings of active PTB such as cavitation; and microscopic examination showed fewer sputum smear AFB positive cases in the elderly. The treatment outcome was less favorable in the elderly compared to younger TB patients.