Pulmonary Tuberculosis – Causes, Symptoms, Diagnosis and Treatment

Case Study:

November 2010:

Abhinav is a class XII student. He is busy gearing up for his board exams. He is buried in his books at least 14 hours a day. And why not? He has high ambitions. He wants to get in to the top engineering college in the country. He gets extremely tired when he returns home from school. His parents are worried about his sudden weight loss. Ahinav is constantly fatigued, breaks in to sweats and shivers often. He ignores it, citing his cramped up schedule as a reason. Abhinav has gulped down 18 bottles of cough syrup in the past three weeks, but his cough doesn’t seem to go away. One morning he coughs out blood. He panics and finally consults a pulmonologist.

Upon examining, it is found that Abhinav has had pulmonary tuberculosis for over a month. He is immediately on a multi-drug treatment

December 2010:

After a month’s treatment, abhinav starts feeling better.

January 2011:

Abhinav discontinues medication

Jan 15, 2011:

Tuberculosis returns

February 2011:

Abhinav dies despite continuing the treatment again.

This is only a fictional case study but this is exactly what happens in India. Read more on tuberculosis and educate others around you.

DO NOT IGNORE TB SYMPTOMS

Image Courtesy: http://static.howstuffworks.com/gif/adam/images/en/tuberculosis-of-the-lungs-picture.jpg

Disease: Tuberculosis

Caused by: Mycobacterium Tuberculosis

Affected Parts: Usually the lungs but can also affect the brain, the kidneys, the heart, bladder (But most often it’s the Lungs; Pulmonary tuberculosis)

According to estimates from WHO (World Health Organization)

• India accounts for one-fifth of the global TB incident cases.

• Each year nearly 2 million people in India develop TB, of which around 0.87 million are infectious cases.

• About 40% of Indian Population is infected with TB bacteria.

• It is estimated that annually around 330,000 Indians die due to TB.

• In India, TB accounts for 17.6 % of deaths from communicable deaths from communicable disease and 3.5% of all cause mortality.

• About 70% of TB patients are aged between 15 to 54 years, most productive period of lifetime.

Symptoms include

• Cough with a progressive increase in production of mucus
• Dry Cough
• Coughing up blood.
• Fever
• Loss of appetite
• Unexplained weight loss
• Night sweats
• Fatigue

Transmission:

People with the disease; active pulmonary TB transmit the disease when they cough, sneeze, spit or even speak. A sneeze can release up to 40,000 droplets. Each of these droplets can transmit the disease. Less then 10-20 bacteria may cause an infection.

This is why it is important to isolate a patient with tuberculosis and any contacts need to be screened and tested. TB transmission, disease progression and severity are also adversely affected by recent increase in HIV emergence. Tuberculosis is one of the earliest opportunistic diseases to develop in HIV infected persons.

Diagnosis:

• Sputum Analysis
• Tuberculin skin test (Mantoux test)
• X Ray

Treatment

• Antituberculosis treatment.

• Due to the chemical structure of the bacterial cell wall, antibiotics are ineffective as the entry in to the cell is hindered.

• Active TB is treated with a combination of antituberculosis drugs.

• Most commonly used drugs are Rifampicin and Isoniazid.

• The DOTS (Directly Observed Treatment Short-course) strategy of tuberculosis treatment recommended by WHO was based on clinical trials done in the 1970s by Tuberculosis Research Centre, Chennai, India. The government of India has made provision to offer these medicines free of cost to patients suffering from the disease. This is executed through a national programme, RNTCP (Revised national tuberculosis control programme)

• Treatment period is usually from 6 – 24 months, depending on organ affected and its severity.

• People with latent infections are treated in special circumstances, to prevent them from progressing to active TB disease later in life.

DO NOT IGNORE THE SYMPTOMS OF TUBERCULOSIS:

• Because the disease is infectious, spreads too quickly and is deadly without proper treatment

• Delayed treatment is risky and an active Pulmonary tuberculosis patient has a 50 % risk of death

• Earlier the diagnosis, easier the treatment

DO NOT DISCONTINUE THE TREATMENT. Complete the full course as advised by your physician

New hope for severe end-stage heart and lung diseases

Problems with the heart and lungs are quite common these days. This could be attributed to a more sedentary lifestyle, increase in smoking habits, alcohol abuse, unhealthy diet and increased levels of pollution (industrial, traffic etc.). Moreover advances in cardiology (study of heart and heart diseases) and pulmonology (study of lung and lung diseases) have improved our understanding of some of these problems. Currently, there is also an increased awareness in the ideal way of managing heart and lung diseases, both medically and by supportive treatments. Supportive therapy using various medications, home oxygen and pulmonary rehabilitation with nebulisers, physiotherapy etc. go a long way in helping patients with extreme breathing difficulty, by improving their quality of life. Unfortunately some patients still lead a very poor quality of life, being unable to perform even simple day to day activities. These patients are said of have reached the end-stage of heart or lung disease. Heart and lung transplantation are accepted forms of treatment for end-stage diseases and may offer new lease of improving the quality of life in such patients.

Heart diseases which do not respond to maximised medical treatment are heart failure due to cardiomyopathy. The term cardiomyopathy refers to severe weakening of the heart muscle with resultant failure to pump blood to the rest of the body. Cardiomyopathy is the result of various heart conditions including ischaemic heart disease. This occurs as a result of recurrent heart attacks that lead to scarring of the heart and subsequently its failure. Cardiomyopathy may also occur with no predetermined cause, in young people and is termed dilated cardiomyopathy. Viral infection to the heart muscles may also produce temporary or permanent heart failure due to cardiomyopathy. Unfortunately the regenerative capacity of the heart muscles are limited and when heart failure happens due to cardiomyopathy, the heart has to be replaced with another human’s heart or supported with artificial heart.

Lung disorders that are progressive and poorly amenable to medical treatment include interstitial lung diseases (including idiopathic pulmonary fibrosis), obstructive lung diseases (end stage emphysema, alpha-1 antitrypsin deficiency) and septic lung diseases (cystic fibrosis and advanced bronchiectasis). The timing of and the suitability of lung transplantation has to be carefully assessed and planned by team of experts including pulmonologists, cardiothoracic surgeons, transplant physicians, physiotherapists and other support groups.

The first human lung transplantation was performed in 1963 and heart transplantation in 1967. It took another 20 years before human heart and lung transplantation could be performed routinely. Most of the recent success is attributed to the development of immunosuppressive medications. Immunosuppressive medications are drugs given to the transplant recipient to suppress the natural immunity of the body from rejecting the new heart or lung. Current immunosuppressive medications are more effective in preventing rejection episodes, though they do come at a cost. The cost would involve increased predilection for infections. Though, this cost also forms part of ‘commonly’ performed transplantation like the kidneys and liver. The monthly financial burden of immunosuppression for heart and lung transplantation are significantly lower when compared to liver transplantation. Unfortunately, the common myth is that since heart and lung perform such important functions in the body, their treatment cost will be higher compared to treatment of other organs.

Heart transplantation is slowly being accepted as a ‘normal’ treatment in India, in the last few years. The Government of Tamil Nadu and its organ allocation systems are encouraging more donor families to donate hearts for transplantation. Though there is no objection for heart or lung transplantation from the State Government, there is still very little lung transplantation being done. Sadly the quality of life in patients with end-stage lung diseases are miserable. These lung diseases apart from being physically crippling, are also mentally debilitating.

There are various types of lung transplantation that can be offered to these patients. Some diseases are amenable to single lung transplantation, i.e., transplantation of one lung. Diseases like cystic fibrosis and bronchiectasis can only be treated with bilateral (both side) lung transplantation. The reason being these patients have chronic (long-term) infection in their lung(s) and doing a single lung transplant will lead to failure of the transplant with the infection from the other side native lung. Some conditions of the lung where the ‘lung pressure’ is higher, tend to affect the heart, causing high pressures on the right side of the heart. These conditions require heart and lung transplantation, at the same time. Most of the heart and lung transplantation is done from donors who have been declared to be brain dead by two different competent medical officers. There are some end-stage lung diseases where a living lobar lung transplantation can be done. This involves taking a part of one lung each from two related donors and transplanting them into the recipient. This method treatment has been successful in several centres around the world, including USA and Japan.

Picture courtesy NHLBI website.

Heart and lung transplantation have a comparatively good long term survival outcome. As with other transplantation, these patients need to take precautions. They should not expose themselves to potential infectious environments like crowded areas, polluted and dusty environments. This is specially necessary for lung transplantation patients as the lungs are the organs that come into direct contact with the environment during each breath. The precaution is also more important in a country like ours, as many people still do not cover their mouth during cough or sneezing, and continue to spit on the roads and pavements. A little care will lead to good long term outcomes, comparable to anywhere else in the world. Moreover, heart and lung transplantation provide a new hope to patients with severe end-stage heart and lung diseases.

Dr J Saravana Ganesh MD (Lond.), DNB (Gen Surg.), FRCS (Glasg), FRCS (Edin)

Dr Madhu MD