A Systematic Review of the Prevalence and Pattern of Imaging Defined Post-TB Lung Disease

Vaccination in post-tuberculosis lung disease management: A review of the evidence

INTRODUCTION AND OBJECTIVES

Post-tuberculosis lung disease (PTLD), as other chronic respiratory disorders, may have infectious complications; some of them can be prevented with vaccinations. So far, no document has discussed the potential role of vaccination in PTLD. Therefore, the objective of this review was to describe vaccination recommendations to prevent infections potentially capable of complicating PTLD.

MATERIALS AND METHODS

A non-systematic review of the literature was conducted. The following keywords were used: tuberculosis, vaccination, vaccines and PTLD. PubMed/MEDLINE and Embase were used as the search engine, focusing on English-language literature only.

RESULTS

We identified 9 vaccines potentially useful in PTLD. Influenza, pneumococcal and anti-COVID-19 vaccinations should be recommended. Patients with PTLD can also benefit from vaccination against shingles. Vaccination against pertussis is mainly relevant during childhood. Diphtheria, tetanus and measles vaccination are recommended for general population and should be considered in patients with PTLD not previously vaccinated. Tdap (Tetanus, diphtheria, and pertussis) booster should be repeated in every adult every ten years. Vaccination against BCG retains its importance during early childhood in countries where TB is endemic.

CONCLUSIONS

Vaccination deserves to be considered among the strategies to prevent and/or mitigate PTLD complications. Further evidence is necessary to better understand which vaccines have the greatest impact and cost-benefit.

Post-tuberculosis lung disease: towards prevention, diagnosis, and care

There is a growing body of data describing the high burden of respiratory sequelae seen among tuberculosis survivors, including children, adolescents, and adults. This group of sequelae are known as post-tuberculosis lung disease and include parenchymal damage, airway disease, and pulmonary vascular disease. It is thought that approximately half of pulmonary tuberculosis survivors have ongoing structural pathology, lung function impairment, or respiratory symptoms after the resolution of active disease. Post-tuberculosis lung disease has been associated with adverse patient outcomes, including persistent symptoms and functional impairment, ongoing health seeking, and impacts on income and employment. There is still much to understand about the epidemiology and nature of post-tuberculosis lung disease, but in this Review we focus on strategies for prevention, diagnosis, and care to inform the ongoing work of tuberculosis-affected communities, health-care providers, researchers, and policy makers. We summarise recent data, highlight evidence gaps, and suggest key research priorities for those working in the field.

Pulmonary Nontuberculous Mycobacteria Infection in Bronchiectasis: A Narrative Review of Current Status and Future

Background and Aims

Pulmonary nontuberculous mycobacteria (NTM) infection and bronchiectasis are two distinct respiratory conditions, but bronchiectasis and pulmonary NTM infections are closely associated. NTM can cause bronchiectasis. However, bronchiectasis can create a favorable environment for NTM colonization and exacerbate the progression of NTM. Managing both conditions typically requires a comprehensive approach that addresses infection and the underlying structural lung damage.

Methods

To perform this review, the author retrieved and assessed relevant articles related to NTM and bronchiectasis that have been published to date from databases, including PubMed/MEDLINE, Scopus, and Google Scholar.

Results

In this review, the close relationship between pulmonary NTM and bronchiectasis is described from the viewpoints of diagnosis, epidemiology, Pseudomonas aeruginosa, host susceptibility, females and NTM, and treatment.

Conclusion

Timely diagnosis and management of NTM infections, especially in individuals with underlying risk factors, are essential to prevent disease progression and improve the quality of life of affected individuals.

Sequelae of Immunocompromised Host Pneumonia

Immunocompromised individuals are at increased risk for opportunistic infections including pneumonia. Pneumonia has long been known to be a leading cause of mortality during induction chemotherapy for acute leukemia and was the first recognized presentation of human immunodeficiency virus (HIV). Even with adequate treatment, there is a wide breadth of postpneumonia sequelae, which is of particular interest in immunocompromised hosts given their increased risk for pneumonia. In this review, we describe the varying complications, presentations, and systems involved in the sequelae of immunocompromised host pneumonia. We focus on people living with HIV, a well-studied heterogenous population, to model immunocompromised hosts.

The prevalence and pattern of post tuberculosis lung disease including pulmonary hypertension from an Australian TB service; a single-centre, retrospective cohort study

INTRODUCTION

Post Tuberculosis Lung Disease (PTLD) is increasingly recognised as a significant cause of morbidity internationally, but has not been described in an Australian setting. We aimed to determine the prevalence of PTLD among adult TB survivors from an Australian TB service and describe the pattens of lung function abnormalities and pulmonary disease, including pulmonary hypertension.

METHODS

We conducted a single-centre retrospective cohort study in Sydney, Australia, including all adults who successfully completed TB treatment between January 2013 and December 2022. Baseline characteristics, post treatment pulmonary function, and thoracic computed tomography (CT) data were analysed to determine the prevalence and patterns of PTLD, defined as any lung function and/or radiological abnormality attributable to TB.

RESULTS

Among 119 confirmed TB patients (mean age 46 ± 21 years, 61% males) PTLD was identified in 81/119 (68%). Pulmonary function testing was available for 51/119 (43%), of whom 38/51(75%) exhibited abnormalities. Obstructive deficits were found in 25/51 (49%), restrictive deficits in 11/51 (22%), and impaired gas transfer capacity in 26/51 (51%). Chest CT scans were completed in 76/119 (64%), with 70/76 (92%) demonstrating significant abnormalities, including pulmonary fibrosis 43/76 (57%), bronchiectasis 22/76 (29%), and emphysema 11/76 (15%). Pulmonary hypertension was suspected in 52/76 (68%) patients based on radiological findings.

CONCLUSION

Despite successful treatment, PTLD was frequently observed among our cohort of Australian TB survivors. Further research into optimal screening practices to diagnose chronic pulmonary diseases and pulmonary hypertension could provide opportunities for earlier intervention and management.

Development of chronic obstructive pulmonary disease after a tuberculosis episode in a large, population-based cohort from Eastern China

BACKGROUND

Although smoking is considered the primary cause of chronic obstructive pulmonary disease (COPD), there is a growing realization that there may be important secondary risk factors. Tuberculosis may lead to lung impairment; however, whether residual lung damage results in clinically significant, long-term outcomes, independent of smoking, has not been well studied. We aimed to investigate the association between tuberculosis and the subsequent development of COPD using a large, population-based cohort study.

METHODS

We conducted a longitudinal cohort study within the Chinese Electronic Health Records Research in Yinzhou study between 2009 and 2021. We followed participants free of COPD at the beginning of the study, and investigated whether previous or current tuberculosis was an important risk factor. Tuberculosis was recorded based on the Chinese National Disease Reporting system which includes all diagnosed cases at the city, provincial and national levels. We assessed the relationship between tuberculosis and COPD using multivariable survival models, adjusting for demographic and lifestyle characteristics, education level, comorbidities and use of medications.

RESULTS

Among 477 046 participants, 198 882 were eligible for inclusion in our analysis. In a multivariable model, pulmonary tuberculosis and all tuberculosis were associated with a 2.57-fold [95% confidence interval (CI), 2.31-2.87)] and 1.67-fold (95% CI, 1.48-1.90) increased COPD risk, respectively. Stronger associations of pulmonary tuberculosis and all tuberculosis with COPD were seen in participants who were elderly, or with lower body mass index or education level (Pinteraction<0.001). People with tuberculosis were at an increased risk of COPD if they were current smokers [adjusted hazard ratio (aHR), 1.40; 95% CI, 1.02-1.93] or non-smokers (aHR, 1.72; 95% CI, 1.50-1.98).

CONCLUSIONS

Persons who developed tuberculosis were at much greater risk of developing COPD, even accounting for smoking and other potential confounders.

Post-TB sequelae in adolescent pulmonary TB survivors

OBJECTIVE

To compare the persistent clinical symptoms, chest X-ray (CXR), spirometry and echocardiography results in adolescent survivors of drug-susceptible (DS) and drug-resistant (DR) pulmonary TB (PTB).

METHODS

This retrospective cohort study was conducted in 52 adolescent PTB survivors. We compared persistent clinical symptoms, CXR, spirometry and echocardiography in DS-TB and DR-TB survivors. χ2 test was used to compare groups (P < 0.05 significant), logistic regression analysis was used to identify risk factors, and Many-Factor Rasch Measurement Version Facets 3.86.0 was used to assess the multi-rater agreement of CXR.

RESULTS

Significant differences were found in persistent clinical symptoms (higher in DS-TB survivors), CXR, and spirometry abnormalities (higher in DR-TB survivors). The echocardiography revealed a low pulmonary hypertension probability in both groups. Adolescent PTB survivors with comorbidity have 1.5 times the risk of developing pulmonary sequelae compared to non-sequelae.

CONCLUSION

Pulmonary sequelae in adolescent PTB survivors were documented in both DS and DR-TB. Monitoring after treatment completion was necessary for PTB survivors, especially in adolescents.

The Incidence, Risk Factors, and Predictive Model of Obstructive Disease in Post-Tuberculosis Patients

Objective

To assess the incidence and risk factors of tuberculosis-associated obstructive pulmonary disease (TOPD) in individuals with treatment-naive pulmonary tuberculosis (PTB) and develop a predictive model to enhance its management.

Methods

The incidence of TOPD among patients with treatment-naive PTB in Xinjiang, China, was followed up for one year. Patient characteristics, such as demographics, medical histories, laboratory test results, lung radiological evidence, and pulmonary function, were collected upon hospital admission and throughout follow-up visits. Risk factors associated with TOPD were evaluated by multivariate logistic regression analysis, and then a predictive model was established using LASSO regression.

Results

Of the 159 included patients, 69 (43.4%) developed TOPD during the follow-up period. Multivariate regression analysis identified age, body mass index, ESR, and symptom duration as significant risk factors. Subsequently, a model formula was derived from these factors to predict TOPD. Utilizing a cut-off value of 0.435, the model demonstrated a sensitivity of 89% and a specificity of 83%.

Conclusion

In Xinjiang, the prevalence of TOPD appears notably high among treatment-naive PTB patients. Our findings, such as the risk factors and predictive model, may facilitate the early detection and improved interventions for TOPD among patients with PTB, potentially leading to better patient outcomes.

Analysis of factors influencing bronchiectasis patients with active pulmonary tuberculosis and development of a nomogram prediction model

Background

To identify the risk factors for bronchiectasis patients with active pulmonary tuberculosis (APTB) and to develop a predictive nomogram model for estimating the risk of APTB in bronchiectasis patients.

Methods

A retrospective cohort study was conducted on 16,750 bronchiectasis patients hospitalized at the Affiliated Hospital of Guangdong Medical University and the Second Affiliated Hospital of Guangdong Medical University between January 2019 and December 2023. The 390 patients with APTB were classified as the case group, while 818 patients were randomly sampled by computer at a 1:20 ratio from the 16,360 patients with other infections to serve as the control group. Relevant indicators potentially leading to APTB in bronchiectasis patients were collected. Patients were categorized into APTB and inactive pulmonary tuberculosis (IPTB) groups based on the presence of tuberculosis. The general characteristics of both groups were compared. Variables were screened using the least absolute shrinkage and selection operator (LASSO) analysis, followed by multivariate logistic regression analysis. A nomogram model was established based on the analysis results. The model's predictive performance was evaluated using calibration curves, C-index, and ROC curves, and internal validation was performed using the bootstrap method.

Results

LASSO analysis identified 28 potential risk factors. Multivariate analysis showed that age, gender, TC, ALB, MCV, FIB, PDW, LYM, hemoptysis, and hypertension are independent risk factors for bronchiectasis patients with APTB (p < 0.05). The nomogram demonstrated strong calibration and discrimination, with a C-index of 0.745 (95% CI: 0.715-0.775) and an AUC of 0.744 for the ROC curve. Internal validation using the bootstrap method produced a C-index of 0.738, further confirming the model's robustness.

Conclusion

The nomogram model, developed using common clinical serological characteristics, holds significant clinical value for assessing the risk of APTB in bronchiectasis patients.

Therapeutic role of respiratory exercise in patients with tuberculous pleurisy

Objective

To observe the efficacy of respiratory exercise in patients with tuberculous pleurisy (TBP).

Methods

A randomized controlled study was conducted including 146 patients diagnosed with TBP and undergoing pleural effusion drainage in Shandong Public Health Clinical Center from June 2020 to December 2022, and the patients were randomly divided into the control group and the respiratory exercise observation group. Pleural effusion drainage time, the difference of pulmonary function, and the degree of pleural hypertrophy between the two groups at 1 and 3 months after treatment were studied.

Results

Compared with the control group, the pleural effusion drainage time of the observation group was shortened, and there was no significant difference between the two groups in terms of lung function and the degree of pleural hypertrophy at 1 month after treatment, while the lung function indexes and the degree of pleural hypertrophy of the observation group were significantly improved compared with that of the control group at 3 months after treatment.

Conclusion

Respiratory exercise can shorten the drainage time of effusion in patients with TBP, and help to improve lung function and alleviate pleural hypertrophy adhesion.

Pathogenesis of Post-Tuberculosis Lung Disease: Defining Knowledge Gaps and Research Priorities at the Second International Post-Tuberculosis Symposium

Post-tuberculosis (post-TB) lung disease is increasingly recognized as a major contributor to the global burden of chronic lung disease, with recent estimates indicating that over half of TB survivors have impaired lung function after successful completion of TB treatment. However, the pathologic mechanisms that contribute to post-TB lung disease are not well understood, thus limiting the development of therapeutic interventions to improve long-term outcomes after TB. This report summarizes the work of the Pathogenesis and Risk Factors Committee for the Second International Post-Tuberculosis Symposium, which took place in Stellenbosch, South Africa, in April 2023. The committee first identified six areas with high translational potential: 1) tissue matrix destruction, including the role of matrix metalloproteinase dysregulation and neutrophil activity; 2) fibroblasts and profibrotic activity; 3) granuloma fate and cell death pathways; 4) mycobacterial factors, including pathogen burden; 5) animal models; and 6) the impact of key clinical risk factors, including HIV, diabetes, smoking, malnutrition, and alcohol. We share the key findings from a literature review of those areas, highlighting knowledge gaps and areas where further research is needed.

Active case finding to detect symptomatic and subclinical pulmonary tuberculosis disease: implementation of computer-aided detection for chest radiography in Viet Nam

Objective

In Viet Nam, tuberculosis (TB) prevalence surveys revealed that approximately 98% of individuals with pulmonary TB have TB-presumptive abnormalities on chest radiographs, while 32% have no TB symptoms. This prompted the adoption of the "Double X" strategy, which combines chest radiographs and computer-aided detection with GeneXpert testing to screen for and diagnose TB among vulnerable populations. The aim of this study was to describe demographic, clinical and radiographic characteristics of symptomatic and asymptomatic Double X participants and to assess multilabel radiographic abnormalities on chest radiographs, interpreted by computer-aided detection software, as a possible tool for detecting TB-presumptive abnormalities, particularly for subclinical TB.

Methods

Double X participants with TB-presumptive chest radiographs and/or TB symptoms and known risks were referred for confirmatory GeneXpert testing. The demographic and clinical characteristics of all Double X participants and the subset with confirmed TB were summarized. Univariate and multivariable logistic regression modelling was used to evaluate associations between participant characteristics and subclinical TB and between computer-aided detection multilabel radiographic abnormalities and TB.

Results

From 2020 to 2022, 96 631 participants received chest radiographs, with 67 881 (70.2%) reporting no TB symptoms. Among 1144 individuals with Xpert-confirmed TB, 51.0% were subclinical. Subclinical TB prevalence was higher in older age groups, non-smokers, those previously treated for TB and the northern region. Among 11 computer-aided detection multilabel radiographic abnormalities, fibrosis was associated with higher odds of subclinical TB.

Discussion

In Viet Nam, Double X community case finding detected pulmonary TB, including subclinical TB. Computer-aided detection software may have the potential to identify subclinical TB on chest radiographs by classifying multilabel radiographic abnormalities, but further research is needed.

Epidemiology of bronchiectasis

Bronchiectasis is a chronic respiratory disease characterised by permanent enlargement of the airways associated with cough, sputum production and a history of pulmonary exacerbations. In the past few years, incidence and prevalence of bronchiectasis have increased worldwide, possibly due to advances in imaging techniques and disease awareness, leading to increased socioeconomic burden and healthcare costs. Consistently, a mortality increase in bronchiectasis patient cohorts has been demonstrated in certain areas of the globe, with mortality rates of 16-24.8% over 4-5 years of follow-up. However, heterogeneity in epidemiological data is consistent, as reported prevalence in the general population ranges from 52.3 to more than 1000 per 100 000. Methodological flaws in the designs of available studies are likely to underestimate the proportion of people suffering from this condition worldwide and comparisons between different areas of the globe might be unreliable due to different assessment methods or local implementation of the same method in different contexts. Differences in disease severity associated with diverse geographical distribution of aetiologies, comorbidities and microbiology might explain an additional quota of heterogeneity. Finally, limited access to care in certain geographical areas is associated with both underestimation of the disease and increased severity and mortality. The aim of this review is to provide a snapshot of available real-world epidemiological data describing incidence and prevalence of bronchiectasis in the general population. Furthermore, data on mortality, healthcare burden and high-risk populations are provided. Finally, an analysis of the geographical distribution of determinants contributing to differences in bronchiectasis epidemiology is offered.

Post-tuberculosis lung disease: Addressing the policy gap

The burden of long-term functional impairment following curative treatment for tuberculosis (TB) constitutes a significant global health problem. By some estimates, chronic respiratory impairment, or post-tuberculosis lung disease (PTLD), is present in just over half of all patients who have completed TB therapy. Despite this high prevalence and substantial associated morbidity, discussion of PTLD is essentially absent from international and national TB policies and guidelines. Clear and ambitious clinical standards should be established for the diagnosis and management of PTLD, including the stipulation that all patients completing TB therapy should be screened for PTLD. Patients diagnosed with PTLD should receive linkage to chronic care, with access to inhalers and home oxygen, as indicated based on individual symptoms and pathophysiology. Leveraging their considerable influence, major funders, such as The Global Fund, could help close the gap in PTLD care by including PTLD in their strategic vision and funding streams. Immediate action is needed to address the substantial burden of disease associated with PTLD. This will require expanding the global approach to TB to include a commitment to diagnosing and treating long-term complications following initial curative therapy.

Tuberculosis Diagnosis: Current, Ongoing, and Future Approaches

Tuberculosis (TB) remains an impactful infectious disease, leading to millions of deaths every year. Mycobacterium tuberculosis causes the formation of granulomas, which will determine, through the host-pathogen relationship, if the infection will remain latent or evolve into active disease. Early TB diagnosis is life-saving, especially among immunocompromised individuals, and leads to proper treatment, preventing transmission. This review addresses different approaches to diagnosing TB, from traditional methods such as sputum smear microscopy to more advanced molecular techniques. Integrating these techniques, such as polymerase chain reaction (PCR) and loop-mediated isothermal amplification (LAMP), has significantly improved the sensitivity and specificity of M. tuberculosis identification. Additionally, exploring novel biomarkers and applying artificial intelligence in radiological imaging contribute to more accurate and rapid diagnosis. Furthermore, we discuss the challenges of existing diagnostic methods, including limitations in resource-limited settings and the emergence of drug-resistant strains. While the primary focus of this review is on TB diagnosis, we also briefly explore the challenges and strategies for diagnosing non-tuberculous mycobacteria (NTM). In conclusion, this review provides an overview of the current landscape of TB diagnostics, emphasizing the need for ongoing research and innovation. As the field evolves, it is crucial to ensure that these advancements are accessible and applicable in diverse healthcare settings to effectively combat tuberculosis worldwide.

Postinfectious Pulmonary Complications: Establishing Research Priorities to Advance the Field: An Official American Thoracic Society Workshop Report

Continued improvements in the treatment of pulmonary infections have paradoxically resulted in a growing challenge of individuals with postinfectious pulmonary complications (PIPCs). PIPCs have been long recognized after tuberculosis, but recent experiences such as the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic have underscored the importance of PIPCs following other lower respiratory tract infections. Independent of the causative pathogen, most available studies of pulmonary infections focus on short-term outcomes rather than long-term morbidity among survivors. In this document, we establish a conceptual scope for PIPCs with discussion of globally significant pulmonary pathogens and an examination of how these pathogens can damage different components of the lung, resulting in a spectrum of PIPCs. We also review potential mechanisms for the transition from acute infection to PIPC, including the interplay between pathogen-mediated injury and aberrant host responses, which together result in PIPCs. Finally, we identify cross-cutting research priorities for the field to facilitate future studies to establish the incidence of PIPCs, define common mechanisms, identify therapeutic strategies, and ultimately reduce the burden of morbidity in survivors of pulmonary infections.

ISCCM Position Statement on the Approach to and Management of Critically Ill Patients with Tuberculosis

Tuberculosis (TB) is an important cause of morbidity and mortality globally. About 3-4% of hospitalized TB patients require admission to the intensive care unit (ICU); the mortality in these patients is around 50-60%. There is limited literature on the evaluation and management of patients with TB who required ICU admission. The Indian Society of Critical Care Medicine (ISCCM) constituted a working group to develop a position paper that provides recommendations on the various aspects of TB in the ICU setting based on available evidence. Seven domains were identified including the categorization of TB in the critically ill, diagnostic workup, drug therapy, TB in the immunocompromised host, organ support, infection control, and post-TB sequelae. Forty-one questions pertaining to these domains were identified and evidence-based position statements were generated, where available, keeping in focus the critical care aspects. Where evidence was not available, the recommendations were based on consensus. This position paper guides the approach to and management of critically ill patients with TB.

How to cite this article

Chacko B, Chaudhry D, Peter JV, Khilnani G, Saxena P, Sehgal IS, et al. isccm Position Statement on the Approach to and Management of Critically Ill Patients with Tuberculosis. Indian J Crit Care Med 2024;28(S2):S67-S91.

Accuracy of chest x-ray screening of silica-exposed miners for tuberculosis

BACKGROUND

The World Health Organization recommends systematic chest X-ray (CXR) screening for tuberculosis (TB) in silica-exposed workers. However, evidence on the accuracy of CXR screening in such populations is lacking.

AIMS

To measure the accuracy of CXR screening for active TB in silica-exposed miners, in a population with a high prevalence of silicosis, post-TB lung disease and HIV.

METHODS

A secondary analysis of data from a miner screening programme in Lesotho was undertaken. We measured the performance of CXR (in participants with and without cough) for 'abnormalities suggestive of TB' against Xpert MTB/RIF (Xpert). The sample size was 2572 and positive Xpert prevalence was 3%.

RESULTS

CXR alone had high sensitivity (0.93, 95% confidence interval [CI] 0.87-0.99), but low specificity (0.41, 95% CI 0.39-0.42). Requiring cough and a positive CXR increased specificity (0.79, 95% CI 0.77-0.81), resulting in reduced sensitivity (0.41, 95% CI 0.30-0.52). There was no difference in CXR accuracy by HIV status. However, specificity was markedly reduced in the presence of silicosis (from 0.70, 95% CI 0.68-0.72, to 0.03, 95% CI 0.02-0.04) or past TB history (from 0.59, 95% CI 0.56-0.62 to 0.27, 95% CI 0.25-0.29). Throughout, positive predictive value remained very low (5%) and negative predictive value very high (99%).

CONCLUSIONS

CXR screening accurately identifies TB-negative CXRs in this population, but post-TB lung disease and silicosis would result in a high proportion of Xpert-negative referrals and an increased risk of unneeded empirical treatment. Adapted screening algorithms, practitioner training and digital access to previous mining CXRs are needed.

A scoping review of interventions to address TB associated respiratory disability

There is a growing body of data describing a high burden of respiratory morbidity amongst pulmonary TB patients and survivors, with up to half thought to experience residual respiratory symptoms, abnormal spirometry, or structural pathology after TB treatment completion. Many patients experiencing marked impacts on their lives and livelihoods. However, there remain no guidelines or evidence-based frameworks for integrated TB-respiratory care during or post TB treatment completion. In this scoping review, completed in collaboration with the WHO Global Tuberculosis Programme, we have identified a lack of primary data on the clinical efficacy, cost effectiveness or feasibility of six potential interventions for the prevention and management of TB-associated respiratory impairment and disability, with a lack of studies in children and adolescents. There is a need for robust interventional trials to improve the long-term respiratory outcomes of people affected by pulmonary TB disease, and to explore how these might be implemented within resource-limited settings.

Scoping review of post-TB pulmonary vascular disease: Proceedings from the 2nd International Post-Tuberculosis Symposium

Tuberculosis (TB) may cause significant long-term cardiorespiratory complications, of which pulmonary vascular disease is most under-recognized. TB is rarely listed as a cause of pulmonary hypertension (PH) in most PH guidelines, yet PH may develop at various stages in the time course of TB, from active infection through to the post-TB period. Predisposing risk factors for the development of PH are likely multifactorial, involving active TB disease and post-TB lung disease (PTLD), host-related and environment-related factors. Moreover, post-TB PH should likely be classified in Group 3 PH, with the pathogenesis similarly complex and multifactorial as other Group 3 PH causes. Identifying risk factors that predispose to post-TB PH may aid in developing risk stratification criteria for early identification and referral for confirmatory diagnostic tests. Given that universal screening for PH in TB survivors may be impractical and unfeasible, a targeted screening approach for high-risk individuals would be sensible. In this scoping review of post-TB PH, resulting from the proceedings of the 2nd International Post-Tuberculosis Symposium, we aim to describe the epidemiology, risk factors, and pathophysiology of post-TB PH. We emphasize diagnosing PH with an alternative set of diagnostic guidelines in resource-constrained settings where right heart catheterization may not be feasible. Research to describe the burden and distribution of post-TB PH should be prioritized as there is a current gap in knowledge regarding the prevalence and incidence of post-TB PH among persons with TB.

Destroyed lung contributes to the recurrence of hemoptysis after bronchial artery embolization in patients with post-tuberculosis bronchiectasis

BACKGROUND

Bronchiectasis has high rates of hemoptysis and recurrent hemoptysis, which is inconsistent among various etiologies. Idiopathic bronchiectasis and post-tuberculous bronchiectasis are two important etiologies in China, but the differences in clinical features and risk factors of recurrent hemoptysis have not been elucidated.

METHODS

Patients hospitalized for idiopathic bronchiectasis or post-tuberculosis bronchiectasis were included. Patients were followed up for at least 24 months post-BAE. Demographic characteristics and clinical data were collected and analyzed between idiopathic bronchiectasis and post-tuberculosis bronchiectasis. Based on the outcomes of recurrent severe hemoptysis in patients with post-tuberculosis bronchiectasis, Cox regression models were used to identify risk factors for recurrence.

RESULTS

Among 417 patients including 352 idiopathic bronchiectasis and 65 post-tuberculous bronchiectasis, 209 (50.1%) were females. Compared with the idiopathic group, the proportion of patients with female (54.5% vs. 26.2%, p < 0.001), with sputum (79.5% vs. 36.9%, p < 0.001), isolation of Pseudomonas aeruginosa (28.7% vs. 7.7%, p < 0.001), and the number of bronchiectatic lobes≥ 3(98.3% vs 50.8%, p < 0.001) were lower, and the proportion of destroyed lung (4.5% vs. 26.6%, p < 0.001) and recurrence of severe hemoptysis (22.4% vs. 41.5%, p = 0.001) were higher in the post-tuberculous group. Among patients with post-tuberculosis bronchiectasis, destroyed lung [HR: 3.2(1.1,9.1), p = 0.026] and abnormal esophageal proper artery [HR: 2.8(1.1,7.0), p = 0.032] were two independent risk factors for the recurrence of hemoptysis.

CONCLUSIONS

The recurrence rate of severe hemoptysis in patients with post-tuberculous bronchiectasis receiving BAE is high, and the proper esophageal artery should be actively evaluated and standardized treatment should be given.

Chest Radiograph Screening for Detecting Subclinical Tuberculosis in Asymptomatic Household Contacts, Peru

The World Health Organization's end TB strategy promotes the use of symptom and chest radiograph screening for tuberculosis (TB) disease. However, asymptomatic early states of TB beyond latent TB infection and active disease can go unrecognized using current screening criteria. We conducted a longitudinal cohort study enrolling household contacts initially free of TB disease and followed them for the occurrence of incident TB over 1 year. Among 1,747 screened contacts, 27 (52%) of the 52 persons in whom TB subsequently developed during follow-up had a baseline abnormal radiograph. Of contacts without TB symptoms, persons with an abnormal radiograph were at higher risk for subsequent TB than persons with an unremarkable radiograph (adjusted hazard ratio 15.62 [95% CI 7.74-31.54]). In young adults, we found a strong linear relationship between radiograph severity and time to TB diagnosis. Our findings suggest chest radiograph screening can extend to detecting early TB states, thereby enabling timely intervention.

Economic burden of chronic obstructive pulmonary disease and post-tuberculosis sequelae in low- and middle-income countries: a database compiled from a systematic review and meta-analysis

Background

Chronic obstructive pulmonary disease (COPD) and tuberculosis (TB) impose a substantial economic burden globally. This systematic review summarised the evidence on the costs of COPD, including post-TB diseases in low- and middle-income countries.

Methods

A systematic review was conducted and studies published between 1 January 2013 and 28 March 2022 (the date of the search) were identified using various electronic databases without language restrictions. Titles, abstracts and full texts were screened in duplicate and data were extracted and verified by reviewers. Eligible studies were categorised as cost analysis and/or economic burden studies, and costs were converted to 2021 United State dollar. Meta-analysis was conducted on the costs of hospitalisations, medication and outpatient visits.

Results

128 cost studies and 65 economic burden studies were included in this review. The data collected are presented in the Cost Database of COPD and Post-TB (CD-CPTB). The majority of studies were from Asia, Eastern Europe and Latin America, with a few from other middle-income countries. There were extremely limited data on the costs of post-TB sequelae and only a few studies were from Africa (n=6) and low-income (n=5) countries. The direct medical costs of COPD ranged from $26 per hospitalisation in India to $2694 per year per patient with severe disease in Mexico, while the costs of acute exacerbation of COPD ranged from $137 to $4207 per exacerbation with both the minimum and maximum costs occurring in Turkey. The costs were lower in lower middle-income countries compared with upper middle-income countries. Finally, considerable economic burden was attributable to smoking and air pollution.

Conclusion

The review and the CD-CPTB database give a thorough snapshot of the current evidence of the costs and economic burden of COPD and post-TB diseases. Future research is needed to investigate the economic impact after TB treatment and should be prioritised in Africa and low-income countries where there has been a lack of data collection.

Protocol registration number

CRD42022326609.

Risk Factors of Tuberculosis Destroyed Lung in Patients with Pulmonary Tuberculosis and Structural Lung Diseases: A Retrospective Observational Study

Background

Tuberculosis destroyed lung constitutes a significant worldwide public health challenge, little is known about its associated risk factors and prognosis. Our study aimed to identify the risk factors of tuberculosis destroyed lung among pulmonary tuberculosis and structural lung diseases.

Methods

Between January 2019 and December 2021, a case-control study was conducted at the Third People's Hospital of Shenzhen in China. We collected the clinical data among patients with pulmonary tuberculosis and structural lung diseases. Cases were defined as patients with tuberculosis destroyed lung. Controls were not diagnosed with the tuberculosis destroyed lung. A binary logistic regression was performed.

Results

In our study, a total of 341 patients met the inclusion criteria, including 182 cases and 159 controls. We found that age ranges of 46-60 years (aOR: 4.879; 95% CI: 2.338-10.180), >60 years (aOR: 3.384; 95% CI: 1.481-7.735); history of TB treatment (aOR: 2.729; 95% CI: 1.606-4.638); malnutrition (aOR: 5.126; 95% CI: 1.359-19.335); respiratory failure (aOR: 5.080; 95% CI: 1.491-17.306); and bronchiarctia (aOR: 3.499; 95% CI: 1.330-9.209) were the independent risk factors for tuberculosis destroyed lung. Conversely, having a normal (aOR: 0.207; 95% CI: 0.116-0.371) or overweight BMI (aOR: 0.259; 95% CI: 0.090-0.747) emerged as a protective factor against tuberculosis destroyed lung.

Conclusion

This study indicated that tuberculosis destroyed lung is a common condition among patients with pulmonary tuberculosis and structural lung diseases. The independent risk factors for tuberculosis destroyed lung were identified as being within the age groups of 46-60 and over 60 years, having a previous history of TB treatment, malnutrition, respiratory failure, and bronchiarctia. It is essential to closely monitor patients possessing these risk factors to prevent the progression towards tuberculosis destroyed lung.

Incidence and prevalence of chronic pulmonary aspergillosis in patients with post-tuberculosis lung abnormality: Results from a community survey in North India

BACKGROUND

Post-tuberculosis lung abnormality (PTLA) is the most common risk factor for developing chronic pulmonary aspergillosis (CPA). However, the prevalence and incidence of CPA in PTLA patients in India remain unknown.

OBJECTIVES

We aimed to ascertain the incidence and prevalence of CPA in subjects with PTLA.

METHODS

We identified a cohort of pulmonary tuberculosis who completed anti-tuberculosis therapy (ATT) before November 2019 from the records of the 12 tuberculosis treatment centers attached to the national program. We recorded the clinical and demographic details. We performed computed tomography (CT) of the chest and estimated serum A. fumigatus-specific IgG. We categorised subjects as PTLA with or without CPA using a composite of clinical, radiological, and microbiological features. We resurveyed the subjects at 6 months (or earlier) for the presence of new symptoms. We calculated the prevalence and the incidence rate (per 100-person years) of CPA.

RESULTS

We included 117 subjects with PTLA, with a median of 3 years after ATT completion. Eleven subjects had CPA in the initial survey, and one additional case developed CPA during the second survey. The prevalence of CPA in PTLA subjects was 10.3% (12/117). The total observation period was 286.7 person-years. The median (interquartile range) time to develop CPA after ATT completion was 12.5 (5-36.7) months. We found the CPA incidence rate (95% confidence interval) of 4.2 (1.8-6.5) per 100-person years.

CONCLUSION

Chronic pulmonary aspergillosis complicates 10% of PTLA subjects after successful outcomes with ATT. Four new CPA cases may develop per 100-persons years of observation after ATT completion. We suggest screening patients with PTLA who develop new symptoms for CPA.

Burden, clinical features, and outcomes of post-tuberculosis chronic obstructive lung diseases

PURPOSE OF REVIEW

Post-tuberculosis lung disease (PTLD) is an increasingly recognized and debilitating consequence of pulmonary tuberculosis (PTB). In this review, we provide a comprehensive overview of PTLD with airflow obstruction (PTLD-AFO), focusing on its burden, pathophysiology, clinical manifestations, diagnostic methods, and management strategies.

RECENT FINDINGS

The relationship between PTLD and airflow obstruction is complex and multifactorial. Approximately 60% of the patients with PTLD have some spirometric abnormality. Obstruction is documented in 18-22% of PTLD patients. The host susceptibility and host response to mycobacterium drive the pathogenic mechanism of PTLD. A balance between inflammatory, anti-inflammatory, and fibrotic pathways decides whether an individual with PTB would have PTLD after microbiological cure. An obstructive abnormality in PTLD-AFO is primarily due to destruction of bronchial walls, aberrant healing, and reduction of mucosal glands. The most common finding on computed tomography (CT) of thorax in patients with PTLD-AFO is bronchiectasis and cavitation. Therefore, the 'Cole's vicious vortex' described in bronchiectasis applies to PTLD. A multidisciplinary approach is required for diagnosis and treatment. The disability-adjusted life-years (DALYs) attributed to PTLD represent about 50% of the total estimated burden of DALYs due to tuberculosis (TB). Patients with PTLD require comprehensive care that includes psychosocial support, pulmonary rehabilitation, and vaccination against respiratory pathogens. In the absence of trials evaluating different treatments for PTLD-AFO, therapy is primarily symptomatic.

SUMMARY

PTLD with airflow obstruction has considerable burden and causes a significant morbidity and mortality. However, many aspects of PTLD-AFO still need to be answered. Studies are required to evaluate different phenotypes, especially concerning Aspergillus -related complications. The treatment should be personalized based on the predominant phenotype of airflow obstruction. Extensive studies to understand the exact burden, pathogenesis, and treatment of PTBLD-AFO are needed.

Chronic Pulmonary Aspergillosis as a Considerable Complication in Post-Tuberculosis Lung Disease

Post-tuberculosis lung disease (PTLD) has only recently been put in the spotlight as a medical entity. Recent data suggest that up to 50% of tuberculosis (TB) patients are left with PTLD-related impairment after completion of TB treatment. The presence of residual cavities in the lung is the largest risk factor for the development of chronic pulmonary aspergillosis (CPA) globally. Diagnosis of CPA is based on four criteria including a typical radiological pattern, evidence of Aspergillus species, exclusion of alternative diagnosis, and a chronic course of disease. In this manuscript, we provide a narrative review on CPA as a serious complication for patients with PTLD.

Brazilian Thoracic Association recommendations for the management of post-tuberculosis lung disease

Historically, all efforts against tuberculosis were focused on rapid diagnosis and effective treatment to break the chain of transmission of Mycobacterium tuberculosis. However, in the last few years, more and more evidence has been found on the dramatic consequences of the condition defined as post-tuberculosis lung disease (PTLD). Approximately one third of patients surviving pulmonary tuberculosis face considerable ongoing morbidities, including respiratory impairment, psychosocial challenges, and reduced health-related quality of life after treatment completion. Given the important global and local burden of tuberculosis, as well as the estimated burden of PTLD, the development of a consensus document by a Brazilian scientific society-Sociedade Brasileira de Pneumologia e Tisiologia (SBPT)-was considered urgent for the prevention and management of this condition in order to allocate resources to and within tuberculosis services appropriately and serve as a guide for health care professionals. A team of eleven pulmonologists and one methodologist was created by the SBPT to review the current evidence on PTLD and develop recommendations adapted to the Brazilian context. The expert panel selected the topics on the basis of current evidence and international guidelines. During the first phase, three panel members drafted the recommendations, which were divided into three sections: definition and prevalence of PTLD, assessment of PTLD, and management of PTLD. In the second phase, all panel members reviewed, discussed, and revised the recommendations until a consensus was reached. The document was formally approved by the SBPT in a special session organized during the 2023 SBPT Annual Conference.

Global burden of disease due to rifampicin-resistant tuberculosis: a mathematical modeling analysis

In 2020, almost half a million individuals developed rifampicin-resistant tuberculosis (RR-TB). We estimated the global burden of RR-TB over the lifetime of affected individuals. We synthesized data on incidence, case detection, and treatment outcomes in 192 countries (99.99% of global tuberculosis). Using a mathematical model, we projected disability-adjusted life years (DALYs) over the lifetime for individuals developing tuberculosis in 2020 stratified by country, age, sex, HIV, and rifampicin resistance. Here we show that incident RR-TB in 2020 was responsible for an estimated 6.9 (95% uncertainty interval: 5.5, 8.5) million DALYs, 44% (31, 54) of which accrued among TB survivors. We estimated an average of 17 (14, 21) DALYs per person developing RR-TB, 34% (12, 56) greater than for rifampicin-susceptible tuberculosis. RR-TB burden per 100,000 was highest in former Soviet Union countries and southern African countries. While RR-TB causes substantial short-term morbidity and mortality, nearly half of the overall disease burden of RR-TB accrues among tuberculosis survivors. The substantial long-term health impacts among those surviving RR-TB disease suggest the need for improved post-treatment care and further justify increased health expenditures to prevent RR-TB transmission.

South African Thoracic Society position statement on the management of non-cystic fibrosis bronchiectasis in adults: 2023

Background

Bronchiectasis is a chronic lung disorder that affects the lives of many South Africans. Post-tuberculosis (TB) bronchiectasis is an important complication of previous pulmonary TB and a common cause of bronchiectasis in South Africa (SA). No previous statements on the management of bronchiectasis in SA have been published.

Objectives

To provide a position statement that will act as a template for the management of adult patients with bronchiectasis in SA.

Methods

The South African Thoracic Society appointed an editorial committee to compile a position statement on the management of adult non-cystic fibrosis (CF) bronchiectasis in SA.

Results

A position statement addressing the management of non-CF bronchiectasis in adults in SA was compiled. This position statement covers the epidemiology, aetiology, diagnosis, investigations and various aspects of management of adult patients with non-CF bronchiectasis in SA.

Conclusion

Bronchiectasis has largely been a neglected lung condition, but new research has improved the outlook for patients. Collaboration between interprofessional team members in patient management is important. In SA, more research into the epidemiology of bronchiectasis, especially post-TB bronchiectasis and HIV-associated bronchiectasis, is required.

Abstract

The South African Thoracic Society mandated a multidisciplinary team of healthcare providers to compile a position statement on the management of non-cystic fibrosis bronchiectasis in South Africa (SA). International guidelines on the management of bronchiectasis were reviewed and used as a basis from which the current position statement was compiled. This is the first position statement on the management of adult non-cystic fibrosis bronchiectasis in SA. A description of the epidemiology and aetiology of bronchiectasis is provided, as well as guidance on its diagnosis and management. The position statement provides guidance on the management of bronchiectasis to healthcare providers, policymakers and regulatory authorities.

COVID-19 and Tuberculosis: Unveiling the Dual Threat and Shared Solutions Perspective

The year 2020 will likely be remembered as the year dominated by COVID-19, or coronavirus disease. The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), responsible for this pandemic, can be traced back to late 2019 in China. The COVID-19 pandemic has significantly impacted the tuberculosis (TB) care system, reducing TB testing and reporting. This can be attributed to the disruption of TB services and restrictions on patient movement, consequently increasing TB-related deaths. This perspective review aims to highlight the intersection between COVID-19 and TB, highlighting their dual threat and identifying shared solutions to address these two infectious diseases effectively. There are several shared commonalities between COVID-19 and tuberculosis, particularly the transmission of their causative agents, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and Mycobacterium tuberculosis. Both pathogens are transmitted via respiratory tract secretions. TB and COVID-19 are diseases that can be transmitted through droplets and airborne particles, and their primary target is typically the lungs. Regarding COVID-19 diagnostics, several methods are available for rapid and accurate detection. These include RT-PCR, which can provide results within two hours, and rapid antigen test kits that offer results in just a few minutes. The availability of point-of-care self-testing further enhances convenience. On the other hand, various approaches are employed for TB diagnostics to swiftly identify active TB. These include sputum microscopy, sputum for reverse transcription polymerase chain reaction (RT-PCR), and chest X-rays. These methods enable the rapid detection of active TB on the same day, while culture-based testing may take significantly longer, ranging from 2 to 8 weeks. The utilization of diverse diagnostic tools helps ensure the timely identification and management of COVID-19 and TB cases. The quality of life of patients affected by COVID-19 and tuberculosis (TB) can be significantly impacted due to the nature of these diseases and their associated challenges. In conclusion, it is crucial to emphasize the urgent need to address the dual threat of COVID-19 and TB. Both diseases have devastated global health, and their convergence poses an even greater challenge. Collaborative efforts, research investments, and policy reforms are essential to tackle this dual threat effectively.

Surviving Pulmonary Tuberculosis: Navigating the Long Term Respiratory Effects

Tuberculosis is a transmissible disease caused by the bacteria Mycobacterium tuberculosis, which is a cause of significant morbidity and mortality all over the world. Tuberculosis has a number of risk factors, such as living in a developing country, poor ventilation, smoking, male sex, etc., which not only increase the chance of infection but may be independent factors for impairment in pulmonary function as well. In this review article, we have compiled several studies to learn how tuberculosis causes impaired lung function and further explored the long-term effects of tuberculosis on the same. We studied tuberculosis's effect on the lungs even after appropriate treatment and its relationship with obstructive and restrictive lung disorders. A significant relationship exists between chronic respiratory disorders and tuberculosis even after treatment; hence, we believe prevention is far superior to cure.

Residual respiratory disability after successful treatment of pulmonary tuberculosis: a systematic review and meta-analysis

Background

Pulmonary tuberculosis (PTB) can result in long-term health consequences, even after successful treatment. We conducted a systematic review and meta-analysis to estimate the occurrence of respiratory impairment, other disability states, and respiratory complications following successful PTB treatment.

Methods

We identified studies from January 1, 1960, to December 6, 2022, describing populations of all ages that successfully completed treatment for active PTB and had been assessed for at least one of the following outcomes: occurrence of respiratory impairment, other disability states, or respiratory complications following PTB treatment. Studies were excluded if they reported on participants with self-reported TB, extra-pulmonary TB, inactive TB, latent TB, or if participants had been selected on the basis of having more advanced disease. Study characteristics and outcome-related data were abstracted. Meta-analysis was performed using a random effects model. We adapted the Newcastle Ottawa Scale to evaluate the methodological quality of the included studies. Heterogeneity was assessed using the I² statistic and prediction intervals. Publication bias was assessed using Doi plots and LFK indices. This study is registered with PROSPERO (CRD42021276327).

Findings

61 studies with 41,014 participants with PTB were included. In 42 studies reporting post-treatment lung function measurements, 59.1% (I² = 98.3%) of participants with PTB had abnormal spirometry compared to 5.4% (I² = 97.4%) of controls. Specifically, 17.8% (I² = 96.6%) had obstruction, 21.3% (I² = 95.4%) restriction, and 12.7% (I² = 93.2%) a mixed pattern. Among 13 studies with 3179 participants with PTB, 72.6% (I² = 92.8%) of participants with PTB had a Medical Research Council dyspnoea score of 1-2 and 24.7% (I² = 92.2%) a score of 3-5. Mean 6-min walk distance in 13 studies was 440.5 m (I² = 99.0%) in all participants (78.9% predicted, I² = 98.9%) and 403.0 m (I² = 95.1%) among MDR-TB participants in 3 studies (70.5% predicted, I² = 97.6%). Four studies reported data on incidence of lung cancer, with an incidence rate ratio of 4.0 (95% CI 2.1-7.6) and incidence rate difference of 2.7 per 1000 person-years (95% CI 1.2-4.2) when compared to controls. Quality assessment indicated overall low-quality evidence in this field, heterogeneity was high for pooled estimates of nearly all outcomes of interest, and publication bias was considered likely for almost all outcomes.

Interpretation

The occurrence of post-PTB respiratory impairment, other disability states, and respiratory complications is high, adding to the potential benefits of disease prevention, and highlighting the need for optimised management after successful treatment.

Funding

Canadian Institutes of Health Research Foundation Grant.

Difficulties in distinguishing silicosis and pulmonary tuberculosis in silica-exposed gold miners: A report of four cases

Silicosis and tuberculosis (TB) are both global health concerns, with high prevalence among miners from the South African gold mines. Although knowledge has accumulated about these two conditions as distinct diseases since the early 20th century, and despite progress in technology with multiple diagnostic tools and treatment options available for TB, the challenge of distinguishing and therefore efficiently managing these two conditions in this population remains as current as it was 100 years ago. To illustrate the diagnostic and health service problems of distinguishing TB and silicosis clinically and radiologically in former gold miners from the South African mines living in resource-poor areas, we discuss four cases reviewed for this report by a panel of experts. For each case, occupational history, past and current medical history, physical examination, radiological and laboratory findings are described. Common themes are: (1) poor agreement between radiological and clinical presentation; (2) poor agreement between radiology findings and detection of active TB on sputum Xpert MTB/RIF testing; and (3) difficulty in distinguishing the clinical and radiological presentations of silicosis and tuberculosis. Possible consequences at the population level are undertreatment or overtreatment of TB, and underdiagnosis or overdiagnosis of silicosis. There is a need for training of practitioners who are screening or attending to former gold miners in the clinical and radiological features of combined disease, using a curated database of miners' chest X-ray images. Investment in protocols for management of both acute and chronic silicotuberculosis in ex-miners is needed, as is clinical, epidemiologic, and operations research.

Post-TB health and wellbeing

TB affects around 10.6 million people each year and there are now around 155 million TB survivors. TB and its treatments can lead to permanently impaired health and wellbeing. In 2019, representatives of TB affected communities attending the '1st International Post-Tuberculosis Symposium´ called for the development of clinical guidance on these issues. This clinical statement on post-TB health and wellbeing responds to this call and builds on the work of the symposium, which brought together TB survivors, healthcare professionals and researchers. Our document offers expert opinion and, where possible, evidence-based guidance to aid clinicians in the diagnosis and management of post-TB conditions and research in this field. It covers all aspects of post-TB, including economic, social and psychological wellbeing, post TB lung disease (PTLD), cardiovascular and pericardial disease, neurological disability, effects in adolescents and children, and future research needs.

Clinical Profile and Quality of Life of Patients With Post-pulmonary Tuberculosis Sequelae Presenting to a Tertiary Care Hospital

Background and objective There is a dearth of studies on the clinical presentation of patients with post-pulmonary tuberculosis (PTB) sequelae and its impact on their quality of life (QoL). In light of this, we conducted this study to analyze the clinical profile and QoL in patients with post-PTB sequelae. Methods Patients with a history of treated PTB and evidence of radiological damage were enrolled prospectively from November 2018 till June 2020 to study their clinical profile and QoL as per the eligibility criteria. A detailed clinical history was taken along with posteroanterior-view chest X-rays and CT scans of the thorax with bronchial angiography in patients with hemoptysis. QoL was assessed using the Hindi version of St. George's Respiratory Questionnaire (SGRQ) for which permission was obtained from the St. George's University of London. SGRQ scores were calculated using score calculation algorithms (Microsoft Excel-based) and missing data imputation as recommended by its developer. Results A total of 174 patients were included in the analysis. The analyzed population was relatively younger (mean age: 44.27 years) with BMIs leaning toward the lower side of normal (median: 19.6 kg/m²); the majority of the patients were males (59%) and non-smokers (77%). PTB had been diagnosed clinico-radiologically in the majority (68%) of patients with non-compliance to antitubercular treatment (ATT) being reported by only 9% of patients. Multiple courses of ATT were received by about one-third of patients, mainly on a clinico-radiologic basis. Systemic hypertension (HTN) (11%) and diabetes mellitus (DM) (9%) were the most common comorbidities. The most common symptom complex found was cough, expectoration, and dyspnea (n=102, 59%). At least one incidence of massive hemoptysis was reported by 20% of patients. Bronchial artery embolization (BAE) was performed for moderate to massive hemoptysis in 26% of patients with a success rate of >90%. One-fifth of the study participants required hospitalization for exacerbation of respiratory symptoms with more than half of these (59%) requiring ventilatory support. Health-related QoL was significantly impaired as reflected by a median SGRQ total score of 45.53. The most affected domain of QoL was the activity domain (mean score: 45.47). Females had worse QoL as compared to males (p=0.0062), and so did underweight patients (p=0.048). The prolonged duration of the illness also significantly impaired the QoL (p<0.001, r=0.313). Conclusion The sequelae of PTB are under-recognized even among physicians and are frequently misdiagnosed as active PTB. The QoL is more severely affected due to residual damage. This study highlights the clinical profile of this patient population and underscores the need to recognize post-PTB sequelae as a separate entity. An important remedy to mitigate its long-term consequences is its inclusion and recognition in national and international TB guidelines to facilitate its early identification and promote further research to address its evidence-based management.

The Performance of Computer-Aided Detection Digital Chest X-ray Reading Technologies for Triage of Active Tuberculosis Among Persons With a History of Previous Tuberculosis

BACKGROUND

Digital chest X-ray (dCXR) computer-aided detection (CAD) technology uses lung shape and texture analysis to determine the probability of tuberculosis (TB). However, many patients with previously treated TB have sequelae, which also distort lung shape and texture. We evaluated the diagnostic performance of 2 CAD systems for triage of active TB in patients with previously treated TB.

METHODS

We conducted a retrospective analysis of data from a cross-sectional active TB case finding study. Participants ≥15 years, with ≥1 current TB symptom and complete data on history of previous TB, dCXR, and TB microbiological reference (Xpert MTB/RIF) were included. dCXRs were evaluated using CAD4TB (v.7.0) and qXR (v.3.0). We determined the diagnostic accuracy of both systems, overall and stratified by history of TB, using a single threshold for each system that achieved 90% sensitivity and maximized specificity in the overall population.

RESULTS

Of 1884 participants, 452 (24.0%) had a history of previous TB. Prevalence of microbiologically confirmed TB among those with and without history of previous TB was 12.4% and 16.9%, respectively. Using CAD4TB, sensitivity and specificity were 89.3% (95% CI: 78.1-96.0%) and 24.0% (19.9-28.5%) and 90.5% (86.1-93.3%) and 60.3% (57.4-63.0%) among those with and without previous TB, respectively. Using qXR, sensitivity and specificity were 94.6% (95% CI: 85.1-98.9%) and 22.2% (18.2-26.6%) and 89.7% (85.1-93.2%) and 61.8% (58.9-64.5%) among those with and without previous TB, respectively.

CONCLUSIONS

The performance of CAD systems as a TB triage tool is decreased among persons previously treated for TB.

Host-directed immunotherapy of viral and bacterial infections: past, present and future

The advent of COVID-19 and the persistent threat of infectious diseases such as tuberculosis, malaria, influenza and HIV/AIDS remind us of the marked impact that infections continue to have on public health. Some of the most effective protective measures are vaccines but these have been difficult to develop for some of these infectious diseases even after decades of research. The development of drugs and immunotherapies acting directly against the pathogen can be equally challenging, and such pathogen-directed therapeutics have the potential disadvantage of selecting for resistance. An alternative approach is provided by host-directed therapies, which interfere with host cellular processes required for pathogen survival or replication, or target the host immune response to infection (immunotherapies) to either augment immunity or ameliorate immunopathology. Here, we provide a historical perspective of host-directed immunotherapeutic interventions for viral and bacterial infections and then focus on SARS-CoV-2 and Mycobacterium tuberculosis, two major human pathogens of the current era, to indicate the key lessons learned and discuss candidate immunotherapeutic approaches, with a focus on drugs currently in clinical trials.

The prevalence of pulmonary hypertension after successful tuberculosis treatment in a community sample of adult patients

There are an estimated 155 million survivors of tuberculosis (TB). Clinical experience suggests that post tuberculosis lung disease (PTLD) is an important cause of Group 3 pulmonary hypertension (PH). However, TB is not listed as a cause of PH in most guidelines. A cross-sectional, community-based study was conducted in nonhealthcare seeking adults who had successfully completed TB treatment. Subjects underwent questionnaires, spirometry, a 6-min walk distance test (6MWD) and transthoracic echocardiography (TTE). Screen probable PH was defined on TTE as an estimated pulmonary artery peak systolic pressure (PASP) of ≥40 mmHg. One hundred adults (71 males) were enrolled, with a mean age of 42 years (SD 13.8 years) and a median of one TB episode (interquartile range: 1-2). Co-morbidities included hypertension (21%), diabetes (16%), human immunodeficiency virus (10%) and asthma/COPD (5%). Only 25% had no residual symptoms after TB. Probable PH was found in 9%, while 7% had borderline raised PASP values (PASP 35-40 mmHg). An association was found between PH and the number of previous TB episodes, with each additional episode of TB increasing the odds of PH-postTB 2.13-fold (confidence interval [CI]: 1.17-3.88; p = 0.013). All of those found to have PH were smokers or ex-smokers yielding an unadjusted odds ratio for PH-postTB of 3.67 (95% CI: 0.77-17.46). There was no statistical difference in spirometry or 6MWD, between those with and without PH. Neither symptoms nor co-morbidities demonstrated significant association with PH. PH after TB was a common finding in this community-based population. Further research is needed to confirm and determine the significance of these findings.

Magnitude and factors associated with post-tuberculosis lung disease in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND

Emerging evidence suggests that after completion of treatment for tuberculosis (TB) a significant proportion of patients experience sequelae. However, there is limited synthesized evidence on this from low-income countries, from Sub-Saharan Africa, and in HIV infected individuals. We seek to provide an updated comprehensive systematic review and meta-analysis on the magnitude and factors associated with post-TB lung disease (PTLD) in low- and middle-income countries (LMICs).

METHODS

We searched PubMed, Embase and CINAHL for studies from LMICs with data on post-TB lung health in patients who had previously completed treatment for pulmonary TB. Data on study characteristics, prevalence of PTLD-specifically abnormal lung function (spirometry), persisting respiratory symptoms and radiologic abnormalities were abstracted. Statistical analysis was performed using Microsoft Excel and R version 4.1 software, and random effects meta-analysis conducted to compute pooled prevalence of PTLD, evaluate heterogeneity, and assess factors associated with PTLD.

RESULTS

We identified 32 eligible studies with 6225 participants. Twenty-one studies were from Africa, 16 included HIV infected participants, spirometry was conducted in 20 studies, symptom assessment in 16 and chest imaging in eight. Pooled prevalence of abnormal lung function was 46.7%, persistent respiratory symptoms 41.0%, and radiologic abnormalities 64.6%. Magnitude of any type of PTLD varied by HIV status (HIV- 66.9%, HIV+ 32.8%, p = 0.0013), across geographic setting (SE Asia 57.5%, Southern America 50.8%, and Africa 38.2%, p = 0.0118), and across urban-rural settings (symptom prevalence: rural 68.8%, urban 39.1%, mixed settings 27.9%, p = 0.0035), but not by income settings, sex or age-group.

CONCLUSIONS

There is high burden of post-TB persistent respiratory symptoms, functional lung impairment and radiologic structural abnormalities in individuals living in LMICs. Burden varies across settings and by HIV status. This evidence may be valuable to advocate for and inform implementation of structured health care specific to the needs of this vulnerable population of individuals.

New estimation of the prevalence of chronic pulmonary aspergillosis (CPA) related to pulmonary TB - a revised burden for India

Background

Chronic pulmonary aspergillosis (CPA) may be confused with, or a coinfection of, pulmonary tuberculosis (PTB), or may manifest itself after completion of antituberculous therapy (ATT).

Methods

Literature searches were conducted on PubMed. The selected studies stated the timing of CPA diagnosis with respect to PTB. The key assumptions for estimating the annual incidence, annual deaths, and 5-year-period prevalence related to CPA were: of the clinically diagnosed PTB patients , 19% of those HIV-negative had CPA and 7% of HIV-positive patients had CPA; the percentage of patients presenting in the first year after PTB diagnosis or developing CPA as ATT finished was 10%; the annual rate of development of CPA from 2-5 years after PTB diagnosis was 1.5%; and the mortality of CPA was 20% in year 1 and 7.5% thereafter to year 5.

Findings

In India, the annual incidence of CPA arising in PTB patients in 2019 was estimated to be 363 601  cases (range 254 521 - 472 682) and 42 766 deaths (range 29  936-55 595) - 10.5% of total PTB deaths. The 5-year-period prevalence of CPA was estimated at   1 575 716 , with an additional 100 715 deaths' total range of deaths 100 436- 186 525) annually.

Interpretation

The revised estimation indicates a substantial unmet need for better diagnosis of CPA as part of a complex PTB-related respiratory morbidity burden.

Spectrum of pulmonary aspergillus diseases in post TB lung diseases

INTRODUCTION

Post-Pulmonary TB structural lung disease with cavitation and bronchiectasis favours the growth of Aspergillus. It leads to progressive lung destruction and the persistence of symptoms after successful ATT and can mimic smear-negative PTB. There is lack of prevalence study of this disease from India. Antifungal therapy is very beneficial, as it reduces both morbidity and mortality. The present study is being undertaken to study the occurrence of spectrum of PA in PTBLD.

METHODS

This is a prospective observational study, conducted at one of the tertiary chest institute of India over a period of one year, after approval from institutional human ethics committee. A total of 60 patients with history of treatment for PTB were recruited. Active PTB were excluded. Diagnosis of PA in were established on the basis of clinical, radiological, microbiological and serological parameters. Based on this, the spectrum of PA viz. CPA, ABPA and IPA were established.

RESULTS

The mean age was 47.88 ± 12.89 years with males being 60%. Mean duration of illness was 6.57 ± 5.11 years with mean asymptomatic period of 4.97 ± 7.41 year. Cough and breathlessness (100%) being the most common symptom followed by wheezing (58%). PA was diagnosed in 48% of cases out of which 43% cases were of CPA. The most common subtype of CPA was simple aspergilloma 14 (54%) followed by CCPA 10 (38%), 2CFPA (8%). ABPA was diagnosed in two cases of PA and one case of aspergillus sensitization. None of the case diagnosed as IPA.

CONCLUSION

We found high prevalence of PA among PTBLD, especially CPA. Early recognition and treatment with antifungal has the potential to reduce the morbidity and mortality. There is a need of prospective community-based larger multicentric studies to precisely define the prevalence of these disorders.

A cross-sectional study on clinical, demographic, microbiological, and radiological profile of bronchiectasis patients attending a tertiary care teaching center

BACKGROUND

Bronchiectasis is a chronic pulmonary disease characterized by progressive and irreversible bronchial dilatation. The present study aimed to assess the clinical, demographic, microbiological, and radiological features of patients with bronchiectasis.

METHODS

The study population included 60 subjects with bronchiectasis diagnosed by HRCT, who attended the Department of Respiratory Medicine a tertiary care teaching center. A single examiner examined all the 60 participants. Pulmonary function assessment was done on all the subjects on a spirometer, and early-morning sputum samples were taken for culture and sensitivity. Descriptive analysis was carried out by mean and standard deviation for quantitative variables, frequency, and proportion for categorical variables. Categorical outcomes were compared between study groups using the chi-square test. P value <0.05 was considered statistically significant. Co-Guide was used for statistical analysis.

RESULT

The majority of the participants were males (62%). The most common sign observed was crepitations (75%). Pseudomonas aeruginosa (36%) was the primary pathogen isolated from sputum, followed by Klebsiella pneumonia (20%). Drug resistance was highest for ampicillin (56%), and imipenem (100%) was the most sensitive drug.

CONCLUSION

Bronchiectasis is a heterogeneous entity with varied etiologies and multifarious clinic-radiological patterns. The information on etiology and the causative microorganism and antibiotic sensitivity and resistance aids in providing early treatment and thereby improving the lung function of affected individuals.

Stakeholder perspectives around post-TB wellbeing and care in Kenya and Malawi

BACKGROUND

There is growing awareness of the burden of post-TB morbidity, and its impact on the lives and livelihoods of TB affected households. However little work has been done to determine how post-TB care might be delivered in a feasible and sustainable way, within existing National TB Programmes (NTPs) and health systems, in low-resource, high TB-burden settings. In this programme of stakeholder engagement around post-TB care, we identified actors with influence and interest in TB care in Kenya and Malawi, including TB-survivors, healthcare providers, policy-makers, researchers and funders, and explored their perspectives on post-TB morbidity and care.

METHODS

Stakeholder mapping was completed to identify actors with interest and influence in TB care services in each country, informed by the study team's local, regional and international networks. Key international TB organisations were included to provide a global perspective. In person or online one-to-one interviews were completed with purposively selected stakeholders. Snowballing was used to expand the network. Data were recorded, transcribed and translated, and a coding frame was derived. Data were coded using NVivo 12 software and were analysed using thematic content analysis. Online workshops were held with stakeholders from Kenya and Malawi to explore areas of uncertainty and validate findings.

RESULTS

The importance of holistic care for TB patients, which addresses both TB comorbidities and sequelae, was widely recognised by stakeholders. Key challenges to implementation include uncertainty around the burden of post-TB morbidity, leadership of post-TB services, funding constraints, staff and equipment limitations, and the need for improved integration between national TB and non-communicable disease (NCD) programmes for care provision and oversight. There is a need for local data on the burden and distribution of morbidity, evidence-informed clinical guidelines, and pilot data on models of care. Opportunities to learn from existing HIV-NCD services were emphasised.

DISCUSSION

This work addresses important questions about the practical implementation of post-TB services in two African countries, exploring if, how, where, and for whom these services should be provided, according to a broad range of stakeholders. We have identified strong interest in the provision of holistic care for TB patients in Kenya and Malawi, and key evidence gaps which must be addressed to inform decision making by policy makers, TB programmes, and funders around investment in post-TB services. There is a need for pilot studies of models of integrated TB care, and for cross-learning between countries and from HIV-NCD services.

Immunologic and imaging signatures in post tuberculosis lung disease

Post Tuberculosis Lung Disease (PTLD) affects millions of tuberculosis survivors and is a global health burden. The immune mechanisms that drive PTLD are complex and have historically been under investigated. Here, we discuss two immune-mediated paradigms that could drive human PTLD. We review the characteristics of a fibrotic granuloma that favors the development of PTLD via an abundance of T-helper-2 and T-regulatory cells and an upregulation of TGF-β mediated collagen deposition. Next, we discuss the post-primary tuberculosis paradigm and the complex mixture of caseous pneumonia, cavity formation and fibrosis that can also lead to PTLD. We review the delicate balance between cellular subsets and cytokines of the innate and adaptive immune system in conjunction with host-derived proteases that can perpetuate the parenchymal lung damage seen in PTLD. Next, we discuss the role of novel host directed therapies (HDT) to limit the development of PTLD and in particular, the recent repurposing of established medications such as statins, metformin and doxycycline. Finally, we review the emerging role of novel imaging techniques as a non-invasive modality for the early recognition of PTLD. While access to computed tomography imaging is unlikely to be available widely in countries with a high TB burden, its use in research settings can help phenotype PTLD. Due to a lack of disease-specific biomarkers and controlled clinical trials, there are currently no evidence-based recommendations for the management of PTLD. It is likely that an integrated antifibrotic strategy that could simultaneously target inflammatory and pro-fibrotic pathways will probably emerge as a successful way to treat this complex condition. In a disease spectrum as wide as PTLD, a single immunologic or radiographic marker may not be sufficient and a combination is more likely to be a successful surrogate that could aid in the development of successful HDTs.

The COVID-19 and TB syndemic: the way forward

Together, SARS-CoV-2 and M. tuberculosis have killed approximately 5.7 million people worldwide over the past 2 years. The COVID-19 pandemic, and the non-pharmaceutical interventions to mitigate COVID-19 transmission (including social distancing regulations, partial lockdowns and quarantines), have disrupted healthcare services and led to a reallocation of resources to COVID-19 care. There has also been a tragic loss of healthcare workers who succumbed to the disease. This has had consequences for TB services, and the fear of contracting COVID-19 may also have contributed to reduced access to TB services. Altogether, this is projected to have resulted in a 5-year setback in terms of mortality from TB and a 9-year setback in terms of TB detection. In addition, past and present TB disease has been reported to increase both COVID-19 fatality and incidence. Similarly, COVID-19 may adversely affect TB outcomes. From a more positive perspective, the pandemic has also created opportunities to improve TB care. In this review, we highlight similarities and differences between these two infectious diseases, describe gaps in our knowledge and discuss solutions and priorities for future research.

Transcriptomics for child and adolescent tuberculosis

Tuberculosis (TB) in humans is caused by Mycobacterium tuberculosis (Mtb). It is estimated that 70 million children (<15 years) are currently infected with Mtb, with 1.2 million each year progressing to disease. Of these, a quarter die. The risk of progression from Mtb infection to disease and from disease to death is dependent on multiple pathogen and host factors. Age is a central component in all these transitions. The natural history of TB in children and adolescents is different to adults, leading to unique challenges in the development of diagnostics, therapeutics, and vaccines. The quantification of RNA transcripts in specific cells or in the peripheral blood, using high-throughput methods, such as microarray analysis or RNA-Sequencing, can shed light into the host immune response to Mtb during infection and disease, as well as understanding treatment response, disease severity, and vaccination, in a global hypothesis-free manner. Additionally, gene expression profiling can be used for biomarker discovery, to diagnose disease, predict future disease progression and to monitor response to treatment. Here, we review the role of transcriptomics in children and adolescents, focused mainly on work done in blood, to understand disease biology, and to discriminate disease states to assist clinical decision-making. In recent years, studies with a specific pediatric and adolescent focus have identified blood gene expression markers with diagnostic or prognostic potential that meet or exceed the current sensitivity and specificity targets for diagnostic tools. Diagnostic and prognostic gene expression signatures identified through high-throughput methods are currently being translated into diagnostic tests.

Making cough count in tuberculosis care

Cough assessment is central to the clinical management of respiratory diseases, including tuberculosis (TB), but strategies to objectively and unobtrusively measure cough are lacking. Acoustic epidemiology is an emerging field that uses technology to detect cough sounds and analyze cough patterns to improve health outcomes among people with respiratory conditions linked to cough. This field is increasingly exploring the potential of artificial intelligence (AI) for more advanced applications, such as analyzing cough sounds as a biomarker for disease screening. While much of the data are preliminary, objective cough assessment could potentially transform disease control programs, including TB, and support individual patient management. Here, we present an overview of recent advances in this field and describe how cough assessment, if validated, could support public health programs at various stages of the TB care cascade.

Imaging Approach to Disease of the Pleura

Diseases of pleura are not only common but also have a significant impact on patients' outcomes. While early detection and treatment are imperative in reducing this burden, many pleural entities present similarly, thus posing a diagnostic dilemma for radiologists requiring critical further workup. While chest radiography, CT, and image-guided thoracentesis are primarily utilized as the initial imaging techniques for the workup of pleural diseases, MRI, and FDG-PET/CT are also frequently employed to investigate the root cause of pleural abnormalities. By elucidating the common imaging features of neoplastic, inflammatory, and infectious pleural pathologies, clinicians can quickly and easily differentiate the various pleural diseases, rapidly reach the correct diagnosis, and ultimately improve patient outcomes.