PATTERN OF THE DIAGNOSED TUBERCULOSIS …Ismail3, Mahmoud Ahmed Arafa4, Karima M. Sobhy5 and Effat A.E. Tony6 1 Chest Diseases Department, Faculty of Medicine, Aswan University, Aswan,

117

AL-AZHAR ASSIUT MEDCAIL JOURNAL

AAMJ, VOL (12), NO (3), JULY 2014 SUPPL

PATTERN OF THE DIAGNOSED TUBERCULOSIS CASES IN

AL-AZHAR UNIVERSITY HOSPITALS, CAIRO, EGYPT: 2009-

2013.

Sayed Abd Elsabour Kinawy1, Eman S.M. Sobh

2, Taghreed Abdul-Aziz M.

Ismail3, Mahmoud Ahmed Arafa

4, Karima M. Sobhy

5

and Effat A.E. Tony6

1 Chest Diseases Department, Faculty of Medicine, Aswan University, Aswan,

Egypt

2 Chest Diseases Department, Faculty of Medicine for Girls, Al-Azhar

University, Cairo, Egypt

3 Public health & Community Medicine Department, Faculty of Medicine,

Assiut University, Assiut, Egypt

4 Chest Diseases Department, Faculty of Medicine, Al-Azhar University, Cairo,

Egypt

5 Public health & Community Medicine Department, Faculty of Medicine,

Aswan University, Aswan, Egypt

6 Internal Medicine & Nephrology Unit, Department of Internal Medicine,

Assiut University, Assiut, Egypt

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ABSTRACT

Background: tuberculosis (TB) represents a global health issue. In Egypt

all efforts are directed to early detection and proper management of TB cases.

Objectives: to highlight the pattern of the reported TB cases during the study

period. Methods: The study was conducted in Al-Azhar university hospitals (Al-

Hussein & Bab-Alshaaria), Cairo, Egypt. All patients registered with TB from

January 2009 to December 2013 were included in the study. All data were

coded and statistically analyzed to gain insight into the pattern of TB cases over

the period. Results: we found 654 cases reported during 5 years period. The

mean age of patients infected with tuberculosis was 36.3±15. 4 years, there was

equal number of male and female. In both genders, the highest number of

tuberculosis patient was found in productive age groups. During the 5-year

study period, the highest percentage of cases was newly diagnosed and the

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Sayed Abd Elsabour Kinawy et al


highest frequency of cases was during year 2013 and lowest frequency was

during year 2012. Most of PTB cases (82.5 %) were smear positive. the most

common site for EPTB were lymph node, pleura and bone& joint. Conclusions:

there is decline in total number of TB cases across the studied years except

slight rise in 2013 and most studied cases were newly diagnosed,pulmonary

smear positive cases. In all age groups, PTB was more common than EPTB

except in age group 5-<15 year. Efforts should be directed towards TB

prevention and control highlighted by the changes in the pattern of cases

through early detection and management of both PTB& EPTB.

Keywords: pattern, Pulmonary Tuberculosis, Extrapulmonary Tuberculosis.

Corresponding author: Dr. Eman Sobh; e-mail: [email protected]

INTRODUCTION

Pulmonary tuberculosis is an air-born infectious disease caused by

Mycobacterium tuberculosis [1]. Despite the advances in diagnosis and

treatment, tuberculosis remains a major health problem worldwide [2]. In 2013,

according to world health organization (WHO), an estimated 9.0 million people

developed TB and 1.5 million died from the disease [3]. In Egypt, TB is

considered the most important public health problem after hepatitis C [4, 5].

WHO targets in TB control policy is to decline TB incidence, prevalence and

prevent TB deaths worldwide [6]. This target of decreasing tuberculosis

morbidity and mortality can be achieved by early detection and proper

management of active tuberculosis cases with directly observed therapy short-

course (DOTS), in addition to the compulsory BCG vaccination [7, 8] which

improved the rate of defaulting and prevalence of TB in Egypt [9, 10].

Reporting is essential for action by the tuberculosis control program at local,

and national levels, and for understanding of the magnitude and the distribution

of the tuberculosis problem. Reporting assist the physician in the proper

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management of the case and for epidemiologic evaluation, including the

identification and the examination of source cases and contacts [11].

Objective: is to study the pattern of TB in Al-Azhar University hospitals (Al-

Hussein & Bab-Alshaaria), Cairo, Egypt.

PATIENTS AND METHODS

The present study was descriptive cross sectional study where the records of TB

cases in Al-Azhar university hospitals (Al-Hussein & Bab-Alshaaria), Cairo,

Egypt were revised. These hospitals serve as training centers for medical

undergraduate and postgraduate students of Al-Azhar University and referral

center for other secondary health facilities in Cairo. Data about all diagnosed

TB cases in the study Hospitals were collected during the period from January

1st, 2009 to December 31, 2013. The diagnosis of TB was made according to

National Egyptian TB Control Program (NTP) guidelines of Ministry of Health.

Data management and statisticalAnalysis:

All data were obtained from the hospital tuberculosis records. Data were coded,

entered and cleaned using the Excel program (Microsoft Excel 2007). The pre-

coded cleaned data were transferred to Statistical Package for Social Science

(SPSS) version16.Data analysis was done in the form of univariate analysis:

descriptive statistics (frequency & percent for qualitative data, mean & SD for

quantitative data), Bivariate analysis: cross tabulation. Chi-square test (X2) was

used to test the difference between the proportions of qualitative data. Student t

test was used to compare the mean of two different groups. Statistical

significance level was considered when p-value was less than 0.05.

Ethics approval

Patient identification data was de-identified and coded prior to the analysis and

the study was done according to the recommendations of ethics committee of

our institute.

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RESULTS

Total of 654 cases were diagnosed and registered as tuberculosis during 5 years

(2009-2013). Their age ranged from months to 83 years.

Figure (1): Frequency of TB cases in Al-Azhar university hospitals, Cairo,

Egypt: 2009-2013.

There was decrease of number of TB cases from year 2009 to 2012 with a sharp

decrease in number of cases during 2012 and slight rise in 2013.

Table (1): Characteristics of diagnosed TB cases in Al-Azhar university

hospitals, Cairo, Egypt: 2009-2013. Criteria Frequency (n=654) %

Age group

-< 5 years 6 0.9%

-5-<15 years 23 3.5%

-15-<40 years 392 60.0%

-40-<60 years 172 26.3%

-above 60 61 9.3%

Gender:

-Males 327 50%

-Females 327 50%

Type of TB

-PTB 354 54.1%

-EPTB 300 45.9%

Type of patient

-New 613 93.7%

-Relapse 36 5.5%

-Defaulter 5 0.8%

Table (1) shows that the majority of the studied population were in the

productive age (15-60 years). Each of males and females represented 50.0% of

the diagnosed cases. Pulmonary cases represented about 54% of the total

0

20

40

60

80

100

120

140

160

180

Total TB

PTB

EPTB

121



diagnosed cases versus about 46% for extrapulmonary cases. Most of the cases

(93.7%) were newly diagnosed. Relapsed cases represented 5.5% while

defaulters were less than 1% of the total cases.

Table (2): Age distribution of the patients according to the type of TB in Al-

Azhar university hospitals, Cairo, Egypt: 2009-2013.

Type Mean age t. p.value

Pulmonary TB (n=354) 38.7±15.9 4.4 <0.001

Extrapulmonary TB (n=300) 33.5±14.4

Total TB (n=654) 36.3±15.4

Table (2) shows that extrapulmonary cases were significantly younger than

pulmonary cases.

Figure (2): Type of TB according to age group:

Figure (2) shows that both forms of tuberculosis were common in productive

age groups. Pulmonary cases were more common in all persons aged ≥ 40 years

as well as among those less than 5 years, while extrapulmonary cases were more

common among those between 5-15 years with statistical significant difference

(X2 = 18.7, P-value = 0.0001).

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Table (3): Type and age distribution of TB cases according to patient

gender in Al-Azhar university hospitals, Cairo, Egypt: 2009-2013.

Patient gender

Statistical test P value Male

327

Female

327

Total

654

PTB 207 147 354

X2=22.2 0.0001 58.5% 41.5% 100.0%

EPTB 120 180 300

40.0% 60.0% 100.0%

Mean Age 37.8 ± 15.8 34.9 ± 14.9 36.3±15.4 t-test =2.5 0.01

Table (3) shows that pulmonary cases were significantly higher among male

patients. Also males were significantly older than females.

Figure (3): Type of the patient according to PTB & EPTB in Al-Azhar

university hospitals, Cairo, Egypt: 2009-2013.

Figure (3) shows that most cases were new, relapse were higher among

pulmonary cases than extrapulmonary cases with statistical significant

difference (X2= 10.8, P-value = 0.001)

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Figure (4): Distribution of PTB cases according to smear examination

results in Al-Azhar university hospitals, Cairo, Egypt: 2009-2013.

Figure (4) shows that most PTB cases (73.0%) were smear positive

Table (4): Distribution of PTB cases according to the side and zone affected

in chest X-ray in Al-Azhar university hospitals, Cairo, Egypt: 2009-2013.

No. (354) Percent

Affected side:

-Right side 233 65.8

-Left side 102 28.8

-Bilateral 19 5.4

Affected Zone:

-Upper lung zone 256 72.3%

-Middle lung zone 65 18.4%

-Lower lung zone 19 5.3%

-Diffuse 14 4.0%

Table (4) shows that the right lung was the affected side in more than two thirds

of pulmonary cases. The upper zone of the lung was affected in about three

quarters of the pulmonary cases.

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Table (5): X ray findings in PTB casesin Al-Azhar university hospitals,

Cairo, Egypt: 2009-2013.

Frequency Percent

Reticular or nodular opacities 273 77.1

Cavitations 57 16.2

Homogeneous Opacity 12 3.4

Homogeneous Opacity + diffuse Reticular or nodular

opacities 3 0.8

Reticular or nodular opacities + cavitation 6 1.7

Normal 3 0.8

Total 354 100.0

Table (5) shows that reticular or nodular opacities were the most common

radiologic presentation, however normal radiology exists in a few cases.

Figure (5): Site of the extrapulmonary cases in Al-Azhar university

hospitals, Cairo, Egypt: 2009-2013.

Figure (5) shows that lymph node, pleura and bone& joint represented the most

common organs affected by EPTB (37%, 30% and 16.3% respectively).

** TB pleurisy were higher among males than females (58.9% Vs 41.1%),

Whereas all other types were more common among females with statistical

significant difference (X2= 43.4 , P-value = 0.0001).

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Table (6): Diagnostic methods of EPTB cases in Al-Azhar university

hospitals, Cairo, Egypt: 2009-2013.

Diagnostic method No. (300) Percent

-Biopsy from lesion 256 85.3%

-fine needle aspiration or smear from discharge 35 11.7%

-ADA 4 1.3%

-PCR 3 1.0%

-Clinical findings only 2 0.7%

Table (6) shows that most cases of EPTB diagnosed by biopsy from affected

organ (85.3%) or fine needle aspiration or smear from discharge (11.7%), while

few cases were diagnosed on base of biomarkers eg Adenosine deaminase or

PCR and only 2 cases (0.7%) diagnosed on clinical bases.

Figure (6): History of positive contact among tuberculosis cases in Al-

Azhar university hospitals, Cairo, Egypt: 2009-2013.

Figure (6) shows that history of positive TB contact was significantly higher

among PTB cases than EPTB cases (23.4% versus 1.7% respectively) with

statistical significant difference (X2 = 66.2, P-value = 0.0001).

DISCUSSION

In this study we reviewed the records of TB cases diagnosed and treated at Al-

Azhar University Hospitals (Bab-Elshaeria &Al-Hussein) from January 1, 2009,

through December 31, 2013. We found 654 cases registered for TB during the

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study period. The number of registered cases show decline from 2009 to 2012

with the lowest number recorded during 2012 then rise of number of registered

cases during 2013 (figure 1).This may reflect the annual behavior of

tuberculosis in many countries as reported slow decline of TB incidence

worldwide except in countries with high burden of TB as reported by WHO;

there was decline in TB incidence in many countries. On average, the decline

was fastest in high-income countries [5]; a 1.3% per year average reduction rate

has been observed since 2002, reaching 2.2% between 2010 and 2011. The

absolute number of cases is also currently decreasing, though this declining

trend only began in 2006 [12]. This reduction was attributed to the progressive

introduction of the DOTS strategy which, by emphasizing bacteriological

diagnosis and standard short-course chemotherapy with direct observation of

treatment, may have significantly contributed to the reduction of chronic and

untreated cases, as well as to the duration of illness [12]. However; in the

current study, the following rise in TB cases during 2013 may reflect improved

notification rate or actual increase in cases. The same explanation has been

reported in WHO report studying worldwide trends of tuberculosis among 134

countries; they found that notifications were highly variable between years

(usually an indication of unreliable notification systems); or an upward trend

was likely to have been affected by efforts to increase case detection or to notify

a greater proportion of detected cases. Improved case finding often leads to

steep rises in annual case notifications – rises greater than 20% on average –

that cannot be due to real increases in TB incidence [5].

In our study, the mean age of total TB cases was 36.3±15.4 year (table 2); most

of them were older than 15 years and most of them (86.3%) were in the

productive age (15-40 years) (table 1). Various studies (13, 14, 15) reported

increased tuberculosis cases in productive age groups. This may be due to high

exposure of this group to infectious agents, high smoking prevalence and

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socioeconomic factors. These results should attract attention to intensive case

detection and early treatment in this group.

It is common to see a J-shaped curve of TB incidence rates by age, with higher

rates in younger children from infancy to pre-adolescence. Rates increase

abruptly during the adolescent years and remain high throughout adulthood,

with a tendency to increase as age progresses, which is particularly notable for

countries with low incidence rates [16]. In this study a lower proportion of

notified childhood tuberculosis cases reflect the same problems reported

worldwide as difficulty in diagnosis or lack of standard case definition and low

awareness of pediatricians about reporting requirements [16].

In this study, PTB cases were more common in all persons aged ≥ 40 years as

well as among those less than 5 years, while EPTB cases were more common

among those between 5-15 years with statistical significant difference (figure 2).

The same trend is present in different countries [9]. Also among persons from

Greenland, the two oldest age groups were significantly less likely to have

EPTB than the youngest age group [17]. On the other hand, patients from

Somalia and Asia, age groups from 25–44 & 45-64 years were more likely to

have EPTB than age group 15–24 years.

In the present study there were equal number of males and females (table 1),

males were significantly older than females (table 3). Although globally men

account for a higher proportion of notified TB cases (around 60-65%), data on

gender differentials in some regions and particular countries show very unusual

patterns [16]. Previous studies [18, 19] reported that TB was more common

among men than women. The high number of affected women reported in this

study contradictory to previous studies may be attributed to female work that

leads to the same exposures of females as well as males (transportations, passive

smoking, pollution….etc) which attenuate gender differences. Also, this study is

in a large city where more healthcare centers are available which improve case

128



detection. On the other hand, Wani et al. [13] reported a higher percentage of

women compared to men. Difference between studies may be attributed to

various biological, social and cultural factors, including access to care, ethnicity

and the influence of the HIV co-epidemic [16].

In the current work pulmonary TB outnumbered EPTB as PTB represented

about 54% of the total diagnosed cases versus about 46% for EPTB cases (table

1). The proportion of EPTB reported in this study (46%) is slightly higher than

that reported in some studies [17, 20-22], however other studies [23, 24]

reported similar or even higher percentages of EPTB. The difference may be

due to different sociodemographic data as age or gender distribution and HIV

infected people included in some studies and excluded in others.

In the current study, regarding history of previous antituberculosis treatment;

the default rate was very low, also small percentage of relapse was detected in

the recorded cases (table 1). This is in line with the national default and relapse

percentages [5], the lower rate recorded in our study may reflect good DOTS

strategy or reporting error as some patients may seek medical advice at other

hospital. The percentage of relapse is much higher for PTB than for EPTB

(figure 3) may be due to easier diagnosis of relapse in PTB as the same

difficulties met in EPTB diagnosis still faced in relapse.

In this study extrapulmonary cases were significantly younger than pulmonary

cases and more common in females (tables2 & 3). This may be attributed to

smoking and environmental exposures are more common in males. The same

results were reported in previous studies [25] as the male to female ratio for

PTB was 2.29. EPTB was more common at younger ages (< 25 years) and in

females. Also males were significantly older than females (table 3). The results

of this study regarding age and gender may be explained by demographic

changes in the population overtime or changes in TB epidemiology over time.

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Studies conducted in different populations showed inconsistent results regarding

an age effect. One study that compared EPTB cases with PTB cases reported

that being younger was a potential risk factor for having EPTB [25]. Another

study reported no significant effect of age on the risk of EPTB, but the adjusted

risk ratios also demonstrated a bimodal distribution [26].

In the current work, most cases of PTB were sputum smear positive (figure 4)

and this is in consistency with previous reports [27]. This finding must raise

attention towards early cases finding and prompt treatment, with

implementation of the proper infection prevention and control guidelines

together with patient and family education and isolation precautions in case of

hospital admission to decrease the airborne transmission. Most cases presented

by chest X-ray (CXR) opacities, the most common form is reticular or nodular

opacities (77%), only 0.8% had normal CXR. On analysis of recorded

radiologic data, we found that PTB was more common in right side and in upper

lung zones (table 4). Reticular or nodular opacities were the most common

radiologic abnormality found. However, only few cases with normal chest x-ray

were detected (table 5). This is the same findings in several studies. Also, the

right side and upper lobes are the site for most airborne infections [28]. In

reactivation TB, the chest radiographs have been regarded to show patchy

consolidation and poorly-defined nodules involving the upper lobes. In one-

third of patients, cavities are present within lung abnormalities [29, 30].

In our study-as regards EPTB-lymph nodes, pleura and bone were the most

common extrapulmonary sites affected (figure 5), and most cases of EPTB were

diagnosed depending on biopsy, few cases by fine needle aspiration, biomarkers

e.g high ADA, clinical bases or DNA replication methods (table 6). The same

results were reported in previous studies [25]. They found that common sites for

EPTB were lymph nodes (42.6%) and peritoneum and/or intestines (14.8%)

[25].

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In the current study history of positive TB contact case were significantly higher

among pulmonary cases than extrapulmonary cases (23.4% versus 1.7%

respectively) with statistical significant difference (figure 6). This is in

consistency with the route of infection of EPTB which is in most cases is

hematogenous spread however; this may reflect the possibility of activation of

latent tuberculosis in PTB group. These findings should raise attention to early

and proper diagnosis of PTB to avoid spread of infection and importance of

screening for latent TB.

CONCLUSION

In conclusion, the present study reported that the proportion of EPTB is

relatively high. Moreover, it was significantly more common among younger

age and female gender. In fact, EPTB is usually not prioritized for case finding

strategies in TB control programs. However, based on our results TB control

programs might usefully target young and female populations for early

diagnosis of EPTB although it is less infectious to decrease TB morbidity and

mortality.

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Documents

PATTERN OF THE DIAGNOSED TUBERCULOSIS …Ismail3, Mahmoud Ahmed Arafa4, Karima M. Sobhy5 and Effat A.E. Tony6 1 Chest Diseases Department, Faculty of Medicine, Aswan University, Aswan,