Copmparative Study of The Characteristics Of Sputum

Positive & Sputum Negative Pulmonarry Tuberculosis

Patients In Alturky Hospitals Submitted in Partial
Fulfillment of the requerment for the
Degree of master of Infectious diseases & tropical
medicine at University of medical science & technology
_Khartoum _ Sugdan _2010
Prepared By

Dr/Rifaat Hassan A. Khatir

M.B.B.ch
Supervised by

Dr/Haithum Benjawi
Medicine Department
University of Medical Science & Technology

INTRODUCTION
Tuberculosis (TB) is a bacterial disease spreads by
infectious air borne droplets containing
Mycobacterium tuberculosis
(occasionally Mycobacterium bovis or africanum)
(Koch, 1932). Once the organism is inhaled, it travels
via the airways to the pulmonary parenchyma
where it
is deposited. Although the organism may be
deposited in
any lobe, a predilection for the lower lobes exists
(Tara,
2005).
The organism is ingested by alveolar macrophages,
which then attempt to phagocytoze the bacilli. As a
result
of the natural defenses of the tubercle bacillus,
alveolar
macrophages may be unsuccessful in attempting
to completely
destroy the bacilli, which then lie dormant within

the macrophage. As a consequence, bacilli often

remain viable
within the macrophages in immunocompetent
individuals.
Subsequently, bacilli may travel via the pulmonary
lymphatics, or they may enter the vascular system
and seed
distant sites such as the liver, spleen, or bone
marrow
(Tara, 2005).
In most immunocompetent individuals,
macrophages
are successful in containing the bacilli, and the
infection is
self-limited and often subclinical. The contained
infection
in immunocompetent hosts is called primary
tuberculosis
In some patients, pulmonary macrophages are
unable to
contain the bacilli and are overwhelmed, leading to
a clinically
apparent infection. This is more common in
patients
who are immunocompromised, notably the
population with
.HIV/AIDS. (Tara, 2005)

This form of tuberculosis is called progressive

primary
tuberculosis. Patients with progressive primary
tuberculosis
may present with pulmonary manifestations (often
with miliary tuberculosis) or with manifestations of
systemic
or disseminated disease (Tara, 2005).

Patients who are exposed to T.B bacilli for the first

time have pathologic, roentgenologic, and clinical
features
different from those who have reactivation of
previous disease.
As a consequence, it is logical to consider the
disease
processes under the separate headings of primary
and postprimary
tuberculosis (Fraser et al., 1994)
Approximately 80% of tuberculosis patients have
pulmonary disease and the remainder have
extrapulmonary
disease with or without pulmonary component.
Among
HIV-coinfected persons, this association is
drastically altered
and may even be reversed. The sites where
extrapulmonary
tuberculosis is most commonly seen, in declining
order of frequency, are the lymph nodes, pleura,
genitourinary
tract, and the bones and joints. Meningeal
tuberculosis
accounts for approximately 1% of cases (Niederman
et al., 2001)
Postprimary (reactivation) tuberculosis is seen in
patients
in whom the initial infection was contained
successfully
by the pulmonary macrophages, with bacilli
remaining
viable within the macrophages. Infection results
when
the host's immune status (T cells) is compromised.
This

form may appear in the elderly population, for

example
.(Tara, 2005 )

Multi-drug-resistant tuberculosis (MDR-TB) is an

increasing global problem, the extent & burden of
which
varies significantly from country to country &
region to region
(Ormerod, 2005).
The prevalence rate of new cases of multidrugresistant
tuberculosis (MDR-TB) was 2.2% while that of
the previously treated tuberculous cases, which
were discovered
to be multi-drug-resistant, was 38%. (WHO, 2004)
A patient is determined to have a MDR-TB only
through laboratory confirmation of in vitro
resistance to at
least Isoniazid & Rifampicin (WHO, 2005).
More than eight million people develop active TB
annually, and approximately two million die from
the disease
each year. The WHO estimate that there are more
than
15 million people living with TB. In 2003, out of
estimation
8.8 million new TB cases worldwide, 3.9 million
were
diagnosed by laboratory testing and 674,000 also
were
HIV+ve. An estimated 1.7 million people died of TB
in

2003, 22 % of whom were co-infected with HIV.

Those
with active TB who receive no treatment can infect
an average
of 10 to 15 people annually. Although TB is curable,
it kills 5000 people every day, 98% of deaths are in
developing
world affecting mostly young adults in their most
productive years. (WHO TB report, 2005

In 2007, 5.5 million TB cases were notified by DO

TS programmes (99% of total case notifications).
This included
2.6 million smear-positive cases. The case
detection
rate of new smear-positive cases under DOTS (that
is, the
percentage of estimated incident cases that were
notified
and treated in DOTS programmes) was 63%, a
small increase
from 62% in 2006 but still 7% short of the target of
70% first set for 2000 (and later reset to 2005)
(WHO
REPORT, 2009)
Based on surveillance and survey data, WHO
estimates
that 9.27 million new cases of TB occurred in 2007
(139 per 100 000 population), compared with 9.24
million
new cases (140 per 100 000 population) in 2006.
Of these
9.27 million new cases, an estimated 44% or 4.1
million

(61 per 100 000 population) were new smearpositive cases

(WHO REPORT, 2009)
Taking a glimpse of the situation in Egypt,
according
to the WHO, in 2007, the estimated incidence of TB
cases
(all forms) is 15873 cases. The estimated
prevalence of TB
cases (all forms) is 27 per 100000 population. The
estimated
annual incidence of new TB cases (all forms) is 21
per 100000 population and 9 per 100000 for smear
positive
TB cases. The mortality rate is 2 per 100000
(excluding
HIV +ve) and _ 1 per 100000 HIV +ve cases , the
prevalence
of which is _ 1 per 100000 as well. (WHO REPORT,
2009)
The WHO targets are that by 2015: The global
burden
of TB (per capita prevalence and death rates) will
be
reduced by 50% relative to 1990 levels. By 2050:
The
global incidence of active TB will be less than 1
case per
million population per year (WHO REPORT, 2009)

Having a capacity of over 600 beds with over 75%

occupied most of the days of the year and being a
referral

center for all upper Egypt, Giza chest hospital has

been
ranked among the most important chest centers in
Egypt
and hence was chosen to be the venue for the
present study.

BACKGROUND:The aim of this study is to review the tuberculous

cases seen in outpatient clinic of Natioal Tuberculosis
Programme in Alturky hospital during the year period
(1/1/2011 31/12/2011)
in evaluation of Characteristics Of Sputum Positive &
Sputum Negative as acomperative study.

OBJETIVES:General :Copmparative Study of The Characteristics Of Sputum

Positive & Sputum Negative Pulmonarry Tuberculosis

Specific:-

1-Study of sputum positive prevalence among the

population
2- prevalence of the patient who remains sputum positive
after two months.
3- Characteristics of patients of Sputum positive positive
versus Sputum negative .
4- Characteristics of X-ray among study population.

METHODOLGY:

A retrospective cross sectional study involving collection of

data of
the tuberculous patients from the records Natioal
Tuberculosis Programme in Alturky hospital .
Giza chest hospital has 14 wards divided as follows:
- Nine wards for males and 4 for females.
- One pediatric ward.
Data will be collected and managed as follows:
1. The total number of patients admitted to the hospital
in the period 2005-2009.

2. Dividing patients into tuberculous cases and

nontuberculous
cases with calculation of their percent of
total cases admitted each year in the aforementioned
.period

3. Results of direct smear sputum examination for acidfast bacilli of tuberculous cases admitted to the
hospital during the period of the study.
4. Results of the culture for acid-fast bacilli, if done, of
tuberculous cases and their percentage per total
tuberculous
cases admitted to the hospital during the
period of the study.
5. Classification of the tuberculous cases according to
the site i.e pulmonary and extrapulmonary.
6. Classification of the tuberculous cases according to
the age and sex of the patient.
7. Classification of the patients according to patient
category i.e. New case, relapsed, defaulter, treatment
failure.
8. Classification of the patients according to treatment
category i.e. CAT I, CAT II, and CAT III
9. Classification of the patients according to the results
of their sputum examination on discharge.
The results will be analyzed, tabulated and discussed

REFERENCES
Fraser, Par (1994): Synopsis of Diseases of The Chest,
Second edition, p. 317
Koch, R. (1932): Die Aetiologie der Tuberculose, a translation
by Berna and Max Pinner with an introduction by Allen
K. Krause. Am Rev. Tubercle; 25: 285. Cited from
Croften and Douglass Fifth edition, vol. 2 Chapter 16
p.476.
Michael S. Niederman, George A. Sarosi, Jeffrey Glassroth
(2001): Respiratory Infection, Second edition, p. 475,

477-478
Ormerod LP (2005): Multidrug-resistant tuberculosis
(MDR-TB): epidemiology, Prevention, and treatment. Br
Med Bull; 73-74:17-24.
Tara M Catanzano, MD(2005), Department of Diagnostic
Radiology, Yale University School of Medicine Lung,
Primary Tuberculosis - September 9, 2005
World Health Organization (2004): Global Tuberculosis
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(WHO/HTM/TB/2004.331). Geneva: WHO.
World Health Organization (2005): Global Tuberculosis
Control: Surveillance, Planning, Financing.
(WHO/HTM/TB2005.349). Geneva: WHO
WHO, Tuberculosis the Global Burden, Sept.2005.
WHO REPORT 2009: Global Tuberculosis Control; p2, 7, 241