Sunil Kumar, B.K.Kapoor, Urvinderpal Singh, Vidhu Mittal Department of Pulmonary Medicine, GMC,Patiala PRESENTATION OF PULMONARY TUBERCULOSIS IN ELDERLY AND YOUNG ADULTS : A COMPARATIVE STUDY

INTRODUCTION AIMS &OBJECTIVES MATERIAL &METHODS OBSERVATIONS & DISCUSSION CONCLUSION

INTRODUCTION  In India, average life expectancy which used to be around 42 in 1960, steadily climbed to around 48 in 1980, 58.5 in 1990 and around 62 in 2000 to 67.3 years in males and 69.6 years for females respectively in  As per the report jointly brought out by United Nations Population Fund (UNFPA), India has around 100 million elderly at present and the number is expected to increase to 323 million, constituting 20 per cent of the total population, by  The geriatric population among all ethnic groups and both genders, represent the largest reservoir of TB infection.

ELDERLY AND TB  Underlying acute or chronic diseases, malnutrition, and the biological changes with aging, can disrupt integumental barriers, impair microbial clearance mechanisms, and contribute to the expected age- associated decline in cellular immune responses to infecting agents such as M.tuberculosis.  There is scarcity of published literature on manifestations of pulmonary tuberculosis (PTB) among elderly patients in India. This paucity of medical literature shows poor attention to geriatric pulmonary tuberculosis in our country.  Some studies have suggested that pulmonary TB in the elderly presents with somewhat atypical symptoms or radiological finding or both. However, some studies have reported that TB in the young adult and elderly patients shows similar clinical, bacteriological and radiological features.

AIMS AND OBJECTIVES To study the differences in clinical and radiological features of pulmonary tuberculosis in elderly (≥ 60 years) patients as compared to young adults (18-59 years).

MATERIAL & METHODS  This prospective study involved 100 sputum smear positive and HIV negative pulmonary tuberculosis patients, which were divided into two groups of 50 elderly (≥ 60 years) and 50 young adults (18-59 years). Demographic, clinical and radiological findings were compared between the two groups. A performa was used to seek detailed history and all cases were subjected to detailed physical examination.

OBSERVATIONS AND DISCUSSION

AGE DISTRIBUTION

SEX DISTRIBUTION

This data was comparable to meta analysis of 12 studies done by Perez Guzman et al, which also showed male predominance in both the groups.

CLINICAL SYMPTOMS

 Cough (100% vs 96%) and fever (70% vs 64%) were seen more commonly in young adults whereas expectoration was more in elderly group as compared to young adults (92% vs 84%),which was similar to the results by Jamal et al.  Breathlessness was seen in 80% of elderly group patients as compared to 46% of young adults, which could be attributed to higher incidence of smoking, COPD and more extensive lesions in elderly patients. Comparative results were observed by Rizvi et al.  28% of young adults while 8% of elderly cases had haemoptysis. Comparable results were observed in the study of Rawat et al and Gupta et al. The higher incidence of cavitation was the probable cause of haemoptysis in young adults..  Loss of appetite (62%vs 52%), loss of weight (54% vs 42%), fatigue (22% vs 2%) and other non specific symptoms (18% vs 10%) were more commonly seen in elderly patients. These results were comparable to Rawat et al and Rizvi et al.

RADIOLOGICAL PRESENTATION TYPE OF CXR LESION

EXTENT OF CXR LESION

SITE OF CXR LESION

 X-ray chest presentation showed that elderly group was having higher involvement of lower lung zone (22% vs 6%), more far advanced lesions (50% vs 44%) and more bilateral wide spread infiltration of lungs (50 % vs 36 %) as compared to young adults.  Whereas young adult patients showed more cavitation (24% vs 12%), more upper zone involvement of lung (24% vs 6%), more of minimal lesions (30% vs 26%) and more unilateral wide spread infiltration of lungs (20% vs 6%) as compared to elderly group.  The results were comparable with Rizvi et al.

COMORBIDITIES

Comorbidities were common in elderly patients as compared to young adults. Hypertension was the most common i.e. in 32% elderly and 4% young adults followed by diabetes mellitus in 22% elderly and 10% young adults followed by COPD in16% elderly and 2% young adults. These were comparable to the results of studies conducted by Rawat et al and Rizvi et al.

H/O IMMUNOSUPPRESSIVE DRUG INTAKE

18% of elderly and 2% of young adults were having history of immunosuppressive drugs. The higher use of immunosuppressive drugs in elderly patients was supposed to be one of the cause of development of tuberculosis in elderly patients.

GRADE OF SMOKING

A higher percentage (48%) of elderly patients were heavy smokers (SI >300) as compared to young adults (14%). Heavy smokers and current smokers have a high risk of developing pulmonary tuberculosis. Comparable results were observed in the study of Gupta et al.

CONCLUSION  Tuberculosis in the elderly is not an uncommon disorder. Unlike many other diseases seen in the elderly, tuberculosis is potentially curable if treated early.  The atypical clinico-radiological manifestation of tuberculosis and association with multiple co-morbities in older persons can result in delay in diagnosis and initiation of treatment. This can lead to unfortunately higher rates of morbidity and mortality from this treatable infection in this population.  So pulmonary tuberculosis should be considered among the differential diagnosis when elderly patients present with multiple medical problems and non specific complaints.

TAKE HOME MESSAGE Tuberculosis in the elderly is a grave disorder because of its association with various co-morbidities which to an extent are responsible for its delayed diagnosis. Tuberculosis should be kept as a possibility in the elderly presenting with non-specific symptoms. Therapy of TB in the elderly is challenging because of the increased incidence of adverse drug reactions.

Thank you