Clinical spectrum of pulmonary tuberculosis in older patients: comparison with younger patients

Clinical spectrum of TB in elderly in a TB & respiratory institution

Tuberculosis has maximum burden among young population in developing countries like India. However, children and elderly form a special group where TB may have atypical presentation. This presents with epidemiological, diagnostic and treatment challenges in these groups which may need special attention in the national programmes for TB. Due to atypical presentation, elderly population is vulnerable to frequent misdiagnosis and disease may already be in advanced stage when correct diagnosis is made. Not only this, adjustment of drug dosages and high chances of adverse drug reaction make the management of TB more complicated in elderly. Mortality due to TB is also higher in this group as compared to young patients of TB. This view point briefly highlights the epidemiological, clinical and disease outcome aspects of TB disease in elderly patients.

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.

Quality of life in tuberculosis: a review of the English language literature

INTRODUCTION

Tuberculosis (TB) studies have concentrated on clinical outcomes; few studies have examined the impact of TB on patients' quality of life (QOL).

METHODS

A systematic review of published medical literature using specific MESH terms: [Tuberculosis] and 1-[Outcome], 2-[Outcome Assessment], 3-[Quality of Life], 4-[Mood Disorder], 5-[Cost and Cost Analysis], 6-[Religion], 7-[Perception], 8-[Social Support], 9-[Optimism], 10-[Stress], 11-[Signs and Symptoms], and 12-[Cost of Illness]. This yielded 1972 articles; 60 articles met inclusion criteria and were reviewed.

RESULTS

TB somatic symptoms have been well studied, but there were no studies of effects on physical functioning or general health perceptions. Patients tend to be worried, frustrated, or disappointed by their diagnosis, but it is unknown how emotional health changes with treatment. Diagnosed patients are less likely to find work, and less able to work and care for their families. TB creates the greatest financial burden on the poor. In developing, countries, patients and their families are ostracized by society, and families sometimes ostracize patients; the extent of TB's social stigma in the developed countries is unknown.

CONCLUSION

There has been relatively little research on TB QOL and even less in developed countries. A better understanding may help improve treatment regimens, adherence to treatment, and functioning and well-being of people with TB.

Revised Guidelines for the Diagnosis and Control of Tuberculosis

Despite major progress in the development of new strategies for diagnosing and treating tuberculosis, the disease still remains a major challenge for healthcare workers throughout the world. A number of causes are responsible for this threat but, unfortunately, many of these cannot be resolved easily because of cultural and social factors. Furthermore, not all countries throughout the world have enough financial resources to support educational and therapeutic programmes. The major challenges with tuberculosis are 2-fold: (i) to deal with the growing epidemic around the world (and especially in 'low-income' [developing] countries), and; (ii) to ensure correct use of antituberculosis medications in order to protect these drugs for future use. In 'high-income' countries, a major decline in the incidence of tuberculosis has been observed. Nevertheless, tuberculosis remains an important challenge in some risk groups, particularly the elderly patient, in these countries. The clinical and radiological presentations are often nonspecific, leading to delayed diagnosis and appropriate treatment, which often results in a large proportion of cases being discovered at autopsy only. Considering tuberculosis in the differential diagnosis remains the cornerstone of a fast and accurate diagnosis of this condition. Management of active tuberculosis in the elderly does not differ fundamentally from that in younger patients with respect to outcomes or adverse effects of treatment. However, empirical treatment perhaps may be considered more readily in the elderly patient. Elderly persons infected with tuberculosis at the beginning of the 20th century constitute a large reservoir of latent tuberculosis infection. Furthermore, these individuals are at increased risk of reactivation of this remote infection as their immunological status declines with aging. Compared with the past, modern guidelines are less reluctant to recommend use of tuberculin skin testing, treatment of latent tuberculosis infection in elderly persons, and prevention of transmission of tuberculosis in nursing homes.

Imaging of pulmonary tuberculosis

Tuberculosis, more than any other infectious disease, has always been a challenge, since it has been responsible for a great amount of morbidity and mortality in humans. After a steady decline in the number of new cases during the twentieth century, due to improved social and environmental conditions, early diagnosis, and the development of antituberculous medication, a stagnation and even an increase in the number of new cases was noted in the mid-1980s. The epidemiological alteration is multifactorial: global increase in developing countries; minority groups (HIV and other immunocompromised patients); and elderly patients due to an altered immune status. Other factors that may be responsible are a delayed diagnosis, especially in elderly patients, incomplete or inadequate therapy, and the emergence of multidrug-resistant tuberculosis. The course of the disease and its corresponding clinicoradiological pattern depends on the interaction between the organism and the host response. Classically, pulmonary tuberculosis has been classified in primary tuberculosis, which occurred previously in children, and postprimary tuberculosis, occurring in adult patients. In industrialized countries, however, there seems to be a shift of primary tuberculosis towards adults. Furthermore, due to an altered immunological response in certain groups, such as immunocompromised and elderly patients, an atypical radioclinical pattern may occur. The changing landscape, in which tuberculosis occurs, as well as the global resurgence, and the changed spectrum of the clinical and radiological presentation, justify a renewed interest of radiologists for the imaging features of pulmonary tuberculosis. This article deals with the usual imaging features of pulmonary tuberculosis as well as the atypical patterns encountered in immunodepressed and elderly patients.

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.

Soil, seed and climate: developing a strategy for prevention and management of infections in UK nursing homes

Most studies of nursing home (NH) infections come from the USA and very few from the UK. USA studies lead us to anticipate a rate of 7 infections per 1000 patient days with a point prevalence as high as 16% in UK NH residents. Pneumonia, skin and urine infections would be the most frequent, followed by enteric infection and bacteraemia. Colonization with resistant organisms is increasing in UK NH residents (e.g., MRSA in 4-17%). Surveillance studies are needed in UK NHs to report incidence of infection, residents' characteristics, existence of and adherence to above standards and policies. Trials of effectiveness of different infection control programmes and of NH vs hospital management are required. Management of infection may be a useful marker of quality of care in NHs and therefore of interest to health and local authorities.

Does aging modify pulmonary tuberculosis?: A meta-analytical review

STUDY OBJECTIVES

To evaluate the differences in the clinical, radiologic, and laboratory features of pulmonary tuberculosis (TB) in older patients, as compared to younger patients.

DESIGN

A meta-analysis (the Schmidt-Hunter method) of published works found in MEDLINE and other sources was performed. A total of 12 studies were collected, and each variable was submitted to meta-analysis.

RESULTS

No differences were found between older (>/= 60 years old) and younger TB patients with respect to male predominance, evolution time before diagnosis, prevalence of cough, sputum production, weight loss, fatigue/malaise, radiographic upper lobes lesions, positive acid-fast bacilli in sputum, anemia or hemoglobin level, and serum aminotransferases. A lower prevalence of fever, sweating, hemoptysis, cavitary disease, and positive purified protein derivative, as well as lower levels of serum albumin and blood leukocytes were noticed among older patients. In addition, the older population had a greater prevalence of dyspnea and some concomitant conditions, such as cardiovascular disorders, COPD, diabetes, gastrectomy history, and malignancies.

CONCLUSIONS

This meta-analytical review identified the main differences of older TB patients, as compared to younger TB patients, that should be considered during the diagnostic evaluation. Most of these differences are explained by the already known physiologic changes that occur during aging.

[Distinctive features of tuberculosis in the aged]

INTRODUCTION

Current recrudescence of human tuberculosis is ascribed to HIV. Nevertheless, other at-risk individuals, particularly the elderly, have been reported.

METHODS

A retrospective study aimed at defining distinctive features of tuberculosis in the elderly was conducted. Eighty-two records of patients aged 18 to 64 years were compared to those of 58 patients of 65 years of age and over.

RESULTS

In the French area considered in this study, the elderly represent the most at-risk group. Institutionalization is a significant risk factor for tuberculosis (RR = 4). Despite a past history of tuberculosis and public awareness campaigns, first-intent diagnosis was evoked in only 22% of the older patients. The mean number of infectious localizations was higher in the elderly (1.3/patient) than in younger patients (1.1/patient). Results of tuberculin skin tests are unreliable. Prognosis is poor in the elderly. In the present study, 14 of the 18 encountered deaths occurred in the elderly, of which eight were due to tuberculosis.

CONCLUSION

To decrease the current incidence of tuberculosis, evaluations of preventive measures in the elderly should be validated and implemented, especially in institutionalized patients.

Hospital-acquired infection in elderly patients

Increasing numbers of elderly people are being treated in hospitals and are at particular risk of acquiring infections. The incidence, risk factors and types of hospital-acquired infection (HAI) in the elderly are reviewed. Special reference is made to urinary tract infections, respiratory tract infections, gastrointestinal infections including Clostridium difficile, bacteraemia, skin and soft tissue infections and infections with antibiotic-resistant organisms.

Radiographic spectrum of adult pulmonary tuberculosis in a developed country

SETTING

Bispebjerg Hospital, Department of Pulmonary Medicine P. The referral centre of adult tuberculosis in the municipality of Copenhagen, Denmark.

OBJECTIVE

To evaluate the radiographic spectrum of pulmonary tuberculosis (TB) in adults in a low-prevalence country and to correlate radiographic appearances with bacteriological results, clinical and demographic data.

DESIGN

Retrospective review of medical files on 548 cases with pulmonary TB according to the criteria of WHO.

RESULTS

Usual radiographic pattern of reactivating TB, with upper lobe involvement, was found in 92% (n = 504), eight percent (n = 44) showed unusual X-ray patterns for adults, such as isolated lower lobe infiltrations (n = 19), hilar adenopathy (n = 10), miliary TB (n = 7), tuberculoma (n = 2), pleural effusion (n = 1) and normal chest X-ray (n = 3). Eight-nine percent of cases with cavitary lesions were positive by microscopy.

CONCLUSION

The risk of missing a diagnosis of pulmonary TB may be high if patients present with an X-ray unusual for TB, but this is fortunately seen only in 8% of cases of pulmonary tuberculosis. Unusual X-ray is more commonly found in patients with concomitant disease, such as diabetes and cancer. If chest X-ray shows cavities, but the smear is negative for Mycobacterium, TB is unlikely and further diagnostic procedures should be performed without waiting for culture results.

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

We studied retrospectively 80 elderly patients who had been admitted to hospital with tuberculosis (TB) between January 1988 and June 1993. There were 64 with pulmonary TB and 16 with miliary tuberculosis (MTB). The mean age was 70+/-7.5 years (range 60-88 years) with 56% over 70 years of age. Underlying disease preceding TB was present in 86.3% patients. In the majority of patients clinical manifestations were subtle. Chest X-ray showed involvement of lower lung fields and miliary shadowing in 71.2% (33/80) and 20% (16/80) patients, respectively. The organism was detected in expectorated sputum specimens in 62.5% (50/80). Of the specimens obtained by flexible fibreoptic bronchoscopy (FOB), 61% were positive for acid-fast bacilli (AFB) by films and culture. Drug-induced adverse effects were observed in 17.6% (6/34). In 18 patients (22.5%), the diagnosis of TB was delayed or missed. The overall mortality of 21% (9/43) included seven patients with MTB and two with pulmonary TB. TB was the direct cause of death in the former and a significant contributory cause in the latter.

The effect of age on the presentation of patients with tuberculosis

OBJECTIVE

To study the differences in presentation of young and elderly patients with tuberculosis (TB).

DESIGN

Between January 1991 and December 1992 all patients with TB diagnosed at the Department of Medicine, Prince of Wales Hospital, were recruited into the study. The following data were collected: body weight, coexisting medical problems, presenting symptoms, radiographic appearance, sputum results for acid-fast bacilli and peripheral blood biochemistry. The patients were divided into young ( < 65 years) and elderly ( > or = 65 years) age groups and differences in presentation of the 2 groups were analysed.

RESULTS

There were 78 young and 94 elderly patients with TB. The elderly patients had lower body weight, less haemoptysis but more non-specific complaints (25% vs 1%, P = 0.001). The chest radiographs in the elderly patients were less likely to have upper lobe infiltration (9% vs 37%, P = 0.0002) but more commonly had extensive infiltration of both lungs (17% vs 2%, P = 0.014). The only biochemical abnormality that was more common in the elderly was a low serum albumin level (64% vs 45%, P < 0.05).

CONCLUSION

Elderly patients with TB are more likely to present with non-specific complaints and atypical radiographic appearance. A high index of suspicion and prompt investigations in elderly patients may allow for earlier diagnosis and treatment of TB.

Clinical spectrum of tuberculosis in older patients

OBJECTIVE

To investigate the clinical differences between old and young patients infected with Mycobacterium tuberculosis in a developing country.

DESIGN

Retrospective chart and chest radiograph review.

SETTING

A university-affiliated teaching hospital.

PATIENTS

The medical records of patients with documented tuberculosis (TB) from January 1990 through December 1991 were analyzed. Clinical assessment included sex, age, diagnosis at first visit, past history, symptoms and signs, laboratory data, X-ray findings, bacteriological examinations, outcome, time elapsed from first visit to initiation of anti-TB therapy and the major determinants for starting anti-TB therapy. Statistical significances were analyzed by Student's t test and chi 2 tests.

RESULTS

Among 205 patients with culture-proven TB, 57 were 65 years of age and older (range, 65 to 91; mean, 73) and 148 under 65 years of age (range, 16 to 64; mean, 41). There was a higher incidence of previous TB (26.3% vs. 16.2%) and diabetes mellitus (24.5% vs. 14.3%) in the elderly patients. Initial diagnosis of TB at first visit was less frequent in the elderly than in the young group (38.6% vs. 47.3%), although symptoms and signs at first visit were similar in each of the age groups. Radiographic presentation with mass lesions was more frequently encountered in elderly patients (10.5% vs. 2.1%, P < .05). Elapsed time from the first visit to suspicion of TB and the initiation of anti-TB therapy was frequently delayed in elderly patients (22 +/- 23 vs. 13 +/- 20 days, P < .05). The incidence of drug-resistance (39% vs. 16%, P < .05) and unfavorable response to anti-TB therapy (17.5% vs. 3.4%, P < .05) were significantly higher in the older patients.

CONCLUSIONS

Although clinical presentation of TB in the elderly did not differ significantly from that in younger patients, this study showed that diagnosis and treatment were more often delayed in the elderly, and there was a higher incidence of treatment failure.

Miliary tuberculosis in Edinburgh--a comparison between 1984-1992 and 1954-1967

We have reviewed the records of 29 patients notified with miliary tuberculosis in Edinburgh from 1984 to 1992 and compared our findings with those for the 40 patients previously reported in Edinburgh from 1954 to 1967. The incidence of miliary tuberculosis has not changed. Respiratory symptoms of cough and dyspnoea were commoner in 1984-1992 (P < 0.001) perhaps reflecting the increase in mean age at presentation (73.5 vs. 59.4 years; P < 0.001). Mortality was 50% in 1984-1992, significantly higher (P < 0.05) than the 25% recorded in 1954-1967. Forty percent of cases in both time periods were of cryptic miliary disease. The diagnosis of cryptic disease tended to be made more often post-mortem and less often by a trial of anti-tuberculosis chemotherapy in 1984-1992. Our findings emphasize the current poor outcome associated with a diagnosis of miliary tuberculosis. It is important to consider this diagnosis in elderly patients with unexplained pyrexia and implement a trial of specific anti-tuberculosis chemotherapy to confirm it.