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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 1  |  Page : 14-18

Clinico-demographic characteristic of multidrug-resistant pulmonary tuberculosis presenting to tertiary care hospital of India


1 Associate Professor & Head, Department of Pulmonary Medicine, All India Institute of Medical Sciences, Patna, India
2 Senior Resident, Department of Pulmonary Medicine, All India Institute of Medical Sciences, Patna, India

Date of Submission10-Jul-2018
Date of Decision30-Mar-2019
Date of Acceptance02-Nov-2019
Date of Web Publication11-Feb-2020

Correspondence Address:
Dr. Deependra Kumar Rai
Department of Pulmonary Medicine, All India Institute of Medical Science, Patna, Bihar 801505
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacp.jacp_14_18

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  Abstract 


Introduction: Multidrug-resistant tuberculosis (MDR-TB) is emerging as major problem due to poor management of drug-sensitive as well as drug-resistant TB. This study designs to assess clinical-demographic and radiological characteristic of MDR pulmonary tuberculosis. Material and method: This was a retrospective record-based study of 85 MDR pulmonary tuberculosis patients diagnosed in pulmonary medicine department AIIMS Patna between 1st Jan 2016 and 31st Dec 2017. All the socio-demographic and clinical-radiological features of MDR tuberculosis were entered in Microsoft Excel and compared. Results: Total 85 patients were diagnosed with MDR tuberculosis in 2016–2017 period. Seventy four patients fulfil inclusion criteria with mean age of 26.78±15.75. There were 56 (75.67%) males and 18 (24.32%) females. Out of 74 study patients, 19 (25.67%) occur in new cases. The most commonly present symptom in study patients was cough (100%) followed by fever, breathlessness, anorexia, and haemoptysis in decreasing order. On radiological examination, 56.75% patients had bilateral disease. The extent of chest X-ray involvement showed far advanced disease in 18.91% of the patients, moderately advanced disease in 67.56%, and 13.51% of the patients had minimal disease. HIV test result was performed in 58 patients in which 2 patients showed positive result (3.4%). Sputum for AFB was negative in 25 (34.72%) patients. Conclusion: High degree of suspicion was required even in sputum negative pulmonary tuberculosis as almost one-third of patients have sputum negative for acid base bacilli at the time of diagnosis.

Keywords: Chest X-ray, GeneXpert, multidrug resistance tuberculosis


How to cite this article:
Rai DK, Kumar A. Clinico-demographic characteristic of multidrug-resistant pulmonary tuberculosis presenting to tertiary care hospital of India. J Assoc Chest Physicians 2020;8:14-8

How to cite this URL:
Rai DK, Kumar A. Clinico-demographic characteristic of multidrug-resistant pulmonary tuberculosis presenting to tertiary care hospital of India. J Assoc Chest Physicians [serial online] 2020 [cited 2020 Apr 3];8:14-8. Available from: http://www.jacpjournal.org/text.asp?2020/8/1/14/278116




  Introduction Top


World Health Organization defined multidrug-resistant tuberculosis (MDR-TB) as resistance to isoniazid and rifampicin, with or without resistance to other anti tubercular drugs. It is becoming a major concern to human health globally posing a threat to the control of TB. The latest anti-TB drug resistance surveillance[1] data show that 4.1% of new and 19% of previously treated TB cases in the world are estimated to have rifampicin- or multidrug-resistant tuberculosis (MDR/RR-TB). In 2016, an estimated 600,000 new cases of MDR/RR-TB emerged globally. An estimated 1.3 lakh incident MDR-TB patients emerge annually in India which includes 79,000 MDR-TB. [2]

The chest X-ray (CXR) manifestations of pulmonary TB depend on several factors, including age and immune status[3] therefore identifying the influence of HIV on the CXR appearances of MDR-TB may be of value.

MDR-TB is emerging as a major problem due to poor management of drug-sensitive as well as drug-resistant TB. MDR-TB/RR-TB is treatable but is very expensive and requires long duration of treatment and contains potentially toxic drugs.

There are few studies on clinical and demographic characteristics of MDR-TB. This study designs to assess clinical-demographic and radiological characteristic of MDR pulmonary tuberculosis [Table 1], [Figure 1].
Table 1 Characteristic of patients under study (n = 74)

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Figure 1 Showing presenting symptoms of MDR patients. Numbers on Y-axis represent percentage.

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  Materials and Methods Top


This was a hospital-based case series study of 85 confirmed MDR pulmonary tuberculosis patients diagnosed in pulmonary medicine department AIIMS Patna between 1st Jan 2016 and 31st Dec 2017. The study was approved from Institute Ethics Committee, AIIMS Patna. All the patients newly diagnosed with MDR pulmonary tuberculosis in Department of Pulmonary Medicine were included in the study. The patient’s record form was used to extract detailed history, baseline demographic characteristics, clinical findings, radiological observations, routine laboratory investigation like complete blood count, random blood sugar, retroviral status, etc., from record available in department.

The patients having no record of baseline characteristics and laboratory finding or already getting treatment for MDR were excluded from this study.

Because there is no facility of conventional culture or line probe assay (LPA) in our institute, sputum samples were sent to GeneXpert in all the suspected cases of MDR pulmonary tuberculosis. We assume here all Rifampicin resistance in GeneXpert as MDR patients. All MDR patients were referred to drug resistance tuberculosis (DRTB) centre for initiation of Category 4 treatment.

Plain chest posterior-anterior radiographs were taken in all the patients. The radiographs were evaluated by radiologists to detect the extent of involvement. The CXRs were classified using the criteria used by the National Tuberculosis Association of USA. [4]

Minimal lesions are the ones which have slight to moderate density but do not contain demonstrable cavitation. They may involve a small part of one or both the lungs, but the total extent, regardless of distribution, should not exceed the volume of lung on one side that occupies the space above the second chondrosternal junction and the spine of the fourth or body of the fifth vertebra.

Moderately advanced lesions are defined as the lesions which may be present in one or both lungs, but the total extent should not exceed the following limits: disseminated lesions of slight to moderate density that may extend throughout the total volume of one lung or the equivalent in both lungs; dense and confluent lesions limited in extent to one-third the volume of one lung; total diameter of cavitations, if present, should be <4 cm [Figure 2].
Figure 2 Chest X-ray severity and sputum AFB status in study subjects. Numbers on Y-axis represent percentage.

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Far advanced lesions are defined as the lesions which are more extensive than moderately advanced.

The other features on CXR such as unilateral/bilateral and predominant type of lesion consolidation, cavitary fibrosis, pleural effusion were also recorded.

Case definition

New case: A patient who never had treatment for TB, or have taken anti-TB drugs for less than one month.

Previously treated case: A patient who has received one month or more of anti-TB drugs in the past, may have positive or negative bacteriology, and may have disease at any anatomical site.

MDR TB: All the patients in which sputum showed Rifampicin resistance were considered as having MDR-TB.

All the data were entered in Microsoft Excel 2016. The qualitative data were represented as mean±SD and qualitative data in the form of percentage. Means were compared by independent samples t-test. A two-sided p-value less than 0.05 was considered as statistically significant.


  Results Top


Total 85 patients were diagnosed with MDR-TB in 2016–2017 period. Eleven patients were excluded from study group considering absence of clinical details, CXR, or routine blood investigation report. Seventy four patients fulfil inclusion criteria with mean age of 26.78 ± 15.75. [Table 1] shows the socio-demographic profile of the patients under study, and there were 56 (75.67%) males and 18 (24.32%) females.

It was found that 70.27% patients belonged to below poverty line and 35.13% come from Patna city only. Out of 74 study patients, 19 (25.67%) occur in new cases. The total duration of symptom before getting diagnosed as MDR-TB was 8.67±6.58 months. Even in new case patients the total duration of symptom before getting diagnosed was 3.92 ± 3.58 months. The most common presenting symptom in study patients was cough (100%) followed by fever, breathlessness, anorexia, and haemoptysis in decreasing order [Table 1].

On radiological examination 56.75% patients had bilateral disease. The extent of CXR involvement showed far advanced disease in 18.91% of the patients, moderately advanced disease in 67.56%, and 13.51% of the patients had minimal disease. When looking on type of shadow consolidation was found in 89.18% and cavities were detected in 43.24% patients [Table 2].
Table 2 Radiological presentation of study subjects

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Out of 74 patients 14 also undergo sputum pyogenic culture and sensitivity in which eight samples showed no growth and six samples showed growth of Burkholderia in two patients, Klebsiella in two patients, and one patient had  Moraxella More Details caterrhalis.

On blood investigation mean haemoglobin was 10.78 ± 1.49, ESR 32.72 ± 15.77, TLC 12150± 4055, and RBS 125.45± 37.31. HIV test result was performed in 58 patients in which two patients showed positive result (3.4%). Sputum for AFB was positive in 47 (65.27%) patients and in rest of the patients it was negative [Table 3].
Table 3 Blood and sputum − Acid fast bacillus status

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  Discussion Top


This study was aimed at evaluating presenting symptoms, demographic, and radiological characteristics of MDR pulmonary tuberculosis. We assume all Rifampicin resistance TB as MDR-TB, as first national anti-TB drug resistance survey for 2014–2016 (NDRS)[5] also found that all RR-TB patients are resistant to H with/without other first- or second-line drugs. In our study 51.35% patient belong to age group 15–30 years which is less as compared to 67% in one study[6] and 44% suspected cases from Andhra Pradesh. [7] Three-fourth patients are male which are in line with other studies. Some studies[8],[9] have shown male sex as risk factor to develop MDR-TB. The females are more compliant with treatment and therefore less likely to receive inadequate treatment than men.[10] This study shows that MDR-TB is more common in people with poor socioeconomic status and 52 out of 72 patients are below poverty line.

History of anti-TB treatment more than one month in past has been found risk factor for MDR-TB. [11] This study shows that one out of four MDR patients deny history of anti-TB drug in past and considered as primary MDR-TB. Total duration of chest symptomatic before getting diagnosed as MDR were an average 8 months for secondary MDR and 3.6 months in primary MDR. All the patients in our study had cough as presenting symptom. Fever was absent in 14 out of 72 (11.63%) patients while haemoptysis was found in 29.72%.

Blood investigation showed haemoglobin on lower side, higher total leukocyte count, and Neutrophil predominance. Eight patients were found suffering with chronic obstructive pulmonary disease. Six patients (8.3%) were diagnosed as diabetic which is found less (15.69%) than other studies.[12] Sputum for acid fast bacilli was negative in 25 (34.73%) patients.

On radiological examination 56.75% patients have bilateral involvement which is less as compared to other study[13] which shows 100% bilateral involvement. 85% of the MDR TB patients had moderate to far advanced shadows and 43.24% had cavities on CXRs which is more than other studies.[6] In this study 75.67% MDR-TB occur in males who are in line with other studies.[5] HIV positivity was found in 3.2% which is less than other studies[5] (which show about 7%). The strong part of the study is that this is the first study to characterise clinico-radiological features of MDR pulmonary tuberculosis patients from remote areas of Bihar.

This study has certain limitations. First we are labelling MDR just on the basis of Rifampicin resistance detected by GeneXpert. Second, we couldn’t performe other first- and second-line tuberculosis drug sensitivity test as it was not available. Results cannot be generalised because of small sample size and hospital-based study.


  Conclusion Top


Most of the MDR-TB occur in young patients. High degree of suspicion is required even in sputum negative pulmonary tuberculosis as almost one-third of patients have sputum negative for acid base bacilli at the time of diagnosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Global Tuberculosis Report 2017. Geneva: World Health Organization 2017. Licence: CCBY-NC SA 3.0 IGO.  Back to cited text no. 1
    
2.
Central TB Division, Ministry of Health & Family Welfare, Government of India- Annual TB report 2017. Available from: https://tbcindia.gov.in.index [Last accessed on 2018 May 24].  Back to cited text no. 2
    
3.
Leung AN. Pulmonary tuberculosis: the essentials. Radiology 1999;210:307-22.  Back to cited text no. 3
    
4.
Falk A, O’Connor JB, Pratt PC. Classification of pulmonary tuberculosis. In: Falk A, O’Connor JB, Pratt PC, Webb JA, Wier JA, Wolinsky E, eds. Diagnostic Standards and Classification of Tuberculosis. Vol. 12. New York, NY: National Tuberculosis and Respiratory Disease Association 1969. pp. 68-76.  Back to cited text no. 4
    
5.
Ministry of Health and Family Welfare GoI. Report of the first national anti-tuberculosis drug resistance survey, 2014-16, 2018.  Back to cited text no. 5
    
6.
Dholakia YN, Shah DP. Clinical profile and treatment outcomes of drug-resistant tuberculosis before directly observed treatment strategy plus: lessons for the program. Lung India: Official Organ of Indian Chest Society 2013;30:316-20.  Back to cited text no. 6
    
7.
Chadha SS, Sharath BN, Reddy K, Jaju J, Vishnu PH, Rao S et al. Operational challenges in diagnosing multi-drug resistant TB and initiating treatment in Andhra Pradesh, India. PLoS One 2011; 6:e26659.  Back to cited text no. 7
    
8.
Franke MF, Appleton SC, Bayona J, Arteaga F, Palacios E, Llaro K, Shin SS, Becerra MC, Murray MB, Mitnick CD. Risk factors and mortality associated with default from multidrug-resistant tuberculosis treatment. Clin Infect Dis 2012;46:1844-51.  Back to cited text no. 8
    
9.
Faustini A, Hall AJ, Perucci CA. Risk factors for multidrug resistant tuberculosis in Europe: a systematic review. Thorax 2006;61:158-63.  Back to cited text no. 9
    
10.
Merza MA, Farnia P, Tabarsi P, Khazampour M, Masjedi MR, Velayati AA. Anti-tuberculosis drug resistance and associated risk factors in a tertiary level TB centre in Iran: a retrospective analysis. J Infect Dev Ctries 2011;5:511-9.  Back to cited text no. 10
    
11.
Kliiman K, Altraja A. Predictors of extensively drug-resistant pulmonary tuberculosis. Ann Intern Med 2009;150:766-75.  Back to cited text no. 11
    
12.
Dholakia Y, D’souza DT, Tolani MP, Chatterjee A, Mistry NF. Chest X-rays and associated clinical parameters in pulmonary tuberculosis cases from the National Tuberculosis Program, Mumbai, India. Infect Dis Rep 2012;4:e10.  Back to cited text no. 12
    
13.
Datta BS, Hassan G, Kadri SM, Qureshi W, Kamili MA, Singh H et al. Multidrug-resistant and extensively drug resistant tuberculosis in Kashmir, India. J Infect DevCtries 2010;4:19-23.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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