The

Indian Journal of Tuberculosis Vol. XXVIII

New Delhi, January 1981

No. 1

TUBERCULOUS MENINGITIS

Of all the manifestations of Tuberculosis, meningitis is undoubtedly the most serious. Notwithstanding the availability of potent and specific drugs, fatality rate of Tuberculous Meningitis (TBM) still remains considerably high as compared to that of all other manifestations. Even when it is not fatal, the sequela are sometimes so distressing and disabling that the utility of life itself becomes questionable, Our estimates about its incidence are usually based on hospital figures. These are likely to be an understimate and imprecise. How many children die undiagnosed is anybody’s guess. So is the size of the population from which a hospital draws its cases. TBM, however, is a very sensitive index of the prevalence of pulmonary tuberculosis in a community or country. When tuberculosis starts declining, the decline is first seen in younger age groups and in respect of those manifestations which, like miliary and meningeal disease, result from haematogenous dissemination soon after primary infection. The higher the age at first infection, the lesser the risk of haematogenous dissemination. When the infector pool in a community gets reduced, first infection shifts towards higher age groups with resultant reduction in the risk of haematogenous dissemination and, therefore, meningitis. Thus TBM is extremely rare today in low prevalence countries. B.C.G. vaccination is another factor closely linked with its incidence. Introduction of BCG in Sweden in the third decade of this century coincided with the fall in the incidence of TBM and was, therefore, considered to be the cause of it. How much of the decline in TBM was due to protective effect of B.C.G. and how much due to shifting of first infection to higher age groups (as a result of the decline in tuberculosis which had already set in) is difficult to say because protective effect of B.C.G. was not measured then by a controlled trial but assumed from a retrospective analysis. Weighty evidence of the role of B.C.G. was, however, provided by the B.M.R.C. study. There were 5 cases of TBM in about 13,000 unvaccinated controls as against none in equal number of vaccinated children. Though TBM can and does develop even in vaccinated children, it is a common observation that if B.C.G. coverage is adequate, incidence of TBM goes down even in the absence of general decline in tuberculosis on the whole.

The review article in this issue deals exhaustively with the clinical aspects of the disease. A point of utmost importance is that early diagnosis Ind. J. Tub., Vol. XXVIII, No. 1

and prompt starting of treatment are imperative for recovery and prevention of serious complications which might lead to irreversible neurological damage. Aim should be to diagnose a case before signs of neurological involvement appear. It is easier said than done. For early diagnosis, suspicion index of the physician has to be very high because clinical features are protean and equivocal- In a child with unexplained and marked toxaemia, lumbar puncture should not be delayed, especially if there has been a recent contact with an open case of pulmonary tuberculosis. Source of contact is, however, more often an unknown extra-familial case. But even the examination of C.S.F. may not provide clinching evidence to make an unequivocal diagnosis. Failure to find tubercle bacilli in C.S.F. in as high a percentage of cases as in western countries is very striking. Even in the best of hands, say Tuberculosis Research Centre, Madras Laboratory, C.S.F. is not positive in more than 30% or so of cases diagnosed TBM on clinical evidence. And this low figure is definitely not due to any deficiency of technique or diligence. Is it then that many such C.S.F. negative cases are not of TBM but of some other disease simulating tuberculosis? After all, tuberculosis is a notorious mimic! It is obvious that concerted efforts are called for, on priority basis, to solve this problem. Immunology too seems to be opening up a new vista in this field. Animal experiments have shown that immune status of an animal (as judged by tuberculin reaction) and the number and viability of invading bacilli, inter alia, influence the extent and severity of the meningeal involvement and neurological complications. In other words, negative tuberculin reaction in a morbid case with extensive meningeal involvement may not be the result but even the cause of extensive disease, provided of course the response in animals is applicable to man also. This aspect need further studies. Thus, while reduction in the size of the infector pool can prevent TBM to some extent, the gut issues involved are authentic criteria for early diagnosis and means to rectify the factors responsible for neurological damage. It is research in these directions that will be most rewarding.

Ind. J. Tub., Vol. XXVIII, No. 1

REVIEW ARTICLE TUBERCULOUS MENINGITIS IN CHILDREN SATYA GUPTA*

& KAMLESH CHOPRA**

Summary : Tuberculous meningitis in children can have protean manifestations. A child can present with fever, neurologic deficit, lone optic atrophy or may have an acute onset with convulsions and pyrexia. Since isolation of AFB in cerebrospinal fluid is difficult in our milieu and sophisticated investigations for diagnosis are not available even in major teaching institutions, a high index of suspicion is necessary. Early detection and prompt therapy are the most important factors in prognosis.

Robert Whyth in 1768 published the first clinical description of Tuberculous meningitis in his monogram on ‘Dropsy in the brain’ in children. Charles Morehead described accurately the clinical picture and appearances at necropsy in cases of tuberculous meningitis. This is probably the first well recorded description of T.B.M. Baumgarten described the endarteritic changes and Hektoen demonstrated miliary tubercles in the vessel wall involving the media and adventitia. Haemorrhagic parenchymal lesions were described by Bombicci and attributed to venous thrombosis. Rich and MacCordock in 1933 published their classic paper based on experimental studies on human brain and animals and showed that TBM was secondary to a small focus in the cortex or leptomeninges. Dastur observed similar cortical foci in the brain but in a smaller proportion of cases. (Dastur et al, 1973). Tuberculous meningitis (TBM) is the commonest type of neurotuberculosis encountered in children in our country. The frequency of meningitis is closely related with the incidence of primary infection with tubercle bacilli. A sample survey conducted by ICMR (1958) revealed that 1.6% suffered from radiological disease with negative sputum and 0.4% from bacteriologically proven disease. This has been subsequently confirmed by another survey (Raj Narain 1963). The prevalence of tuberculous infection in children 0-4 years age group is 2% and 16.5% in 10-14 years age group. Incidence of TBM varies from 1-4% of total in-patient admissions in different parts of India (Rao, 1972). It is the AFB sputum positive cases who are responsible for dissemination of infection. In a study done by Udani et al (1970) TBM comprised 29.02% of total cases of tuberculosis whereas Benakappa et al (1975) found 47.4% cases of TBM. Although the incidence of TBM

is said to be very high in our country no definite uniform diagnostic criteria are laid down. Aetiology : The etiological agent is Mycobacterium tuberculosis. In majority of the cases the organism belongs to the human type. Recently, atypical mycobacterium tuberculosis has been reported to cause TBM. Pathogenesis : TBM is never a primary manifestation but always occurs as a result of secondary hematogenous dissemination from the site of primary extracranial tuberculous lesion which is frequently in the lung. It usually occurs within the first 6-12 months after the primary infection. The predisposing factors are malnutrition, poor socio-economic status, overcrowded surroundings, antecedent infection with measles and pertussis and head injury. As a result of hematogenous dissemination the tubercle bacilli are lodged principally at two sites : (1) Leptomeninges (2) Brain Parenchyma The miliary tubercles in the leptomeninges are most frequently on the lateral aspect of parietal and temporal lobes on either side of the Sylvian fissure and along the blood vessels at these sites. The parenchymatous lesions in the brain are located at 3 sites. (1) Superficial part of the brain—Rich focus (2) Base of the brain—in the subthalamic and subputaminal region. (3) Along the superolateral surfaces. It is frequently a basal tuberculoma which may be single or multiple. Small cortical granulomatous foci burst out in the leptomeninges. This explains the predominant basal location

From the Department of Pediatrics, Loknayak Jaiprakash Hospital, New Delhi. *Professor and Head of the Department ** Lecturer.

Ind. J. Tub., Vol. XXVIII, No. 1

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SATYA GUPTA AND KAMLESH CHOPRA

of the exudate. The exudate may be scanty but The abnormal movements disappear when usually is very copious, thick and adhesive in hemiplegia supervenes. Meningoencephalitic nature. Sometimes it is plaque like and firmly adhesions are occasionally seen in meningoadherent to underlying tissue. The exudate has cortical tuberculosis. a predilection for the interpeduncular fossa, Infarction : It is caused by inflammation of over the floor of 3rd ventricle, around the optic chiasma, distal ends of the interanal carotid the vessels involved in the basal exudate. It is artery and proximal portion of the middle due to arterial narrowing with or without total meningeal artery. The middle meningeal arteries occlusion causing infarction in the zone supplied are often throttled by the exudate. The exudate by the artery, mostly the middle cerebral artery. extends backwards over the pons and cerebellum The vascular changes occur in the form of periand occupies cisterna ambiens and cisterna arteritis and endarteritis, vascular oedema, pontis, forming a collar which compresses the necrosis and thrombosis. The changes depend brain stem and emerging third cranial nerve, on the calibre of the vessels involved, severity, and blocks the medullocerebellar angles where duration, stage of the disease, and treatment the foramina of luschka open. The blockage of status of the patient. In cases of long duraCSF pathways is responsible for the internal tion, subintimal fibrosis and changes in internal hydrocephalus. Frequently the exudate causes elastica are seen in medium sized vessels. Large external compression and occlusion of large arteries, commonly the middle cerebral artery arteries at the base of the brain. The vessels are involved in the basal exudate and over 50% of the circle of Willis are more frequently involved have infarction in the corresponding zone. than the vessels of the basilar system. Micro- Smaller ischaemic lesions result from damage scopically the vessels reveal a thick fibrotic wall to multiple small vessels or endarteritis. Infrewith total or sub-total occlusion of the lumen. quently haemorrhagic infarcts have been desRarely tubercles are seen on the external surface cribed. The vascular lesions cause various types of hemiplegia, seizures and mental retardation. of the middle meningeal artery. Parenchymal changes

Internal hydrocephalus

Dastur et al (1973) described six main gross parenchymal changes.

In TBM there is (1) blockage of the basal cisterns and medullocerebellar angles and obstruction to the flow of the CSF in the subarachnoid spaces by dense basal leptomeninges. (2) Interference in the absorption of CSF by the arachnoid granulations. Excessive production of CSF does not occur since the ependymal lining of the choroid plexus is damaged by the exudate.

(1) (2) (3) (4) (5) (6)

Ventriculitis Border-zone encephalitis Infarction Internal hydrocephalus Diffuse oedema Tuberculoma

Ventriculitis is less frequently encountered than meningitis. Tubercles on the ependymal lining and choroid plexus, though rare, are of diagnostic value. Border zone encephalitis is caused by the impingement of the meningeal exudate on the underlying brain parenchyma. Frequently there is only a glial reaction, occasionally the changes may be of inflammatory nature with perivascular cuffs of small mononuclear cells. It is seen most frequently in the Sylvian fissure. Hemiballismus is the clinical manifestation of border-zone encephalitis. Causes of hemiballismus movements are : (1) Damage to suprasylvian subthalamic re gion by tenacious exudate penetrating from the sylvian fissure. (2) Damage to connections between the nucleus subthalamus and globus pallidus. Ind. J. Tub., Vol. XXVIII, No. 1

Usually the aqueduct is dilated but sometimes there is subtotal occlusion. The causes are : (1) Compression of aqueduct by oedematous portions of the midbrain. (2) Tuberculoma (3) Ependymitis with exudate and oedema. The internal hydrocephalus causes cerebral atrophy and seizures and mental retardation. However brain oedema may be another cause of diffuse brain damage. Diffuse oedema : It is an important cause of diffuse brain damage seen in the absence of cerebral infarction or tuberculoma or severe hydrocephalus. It is a type of diffuse tuberculous encephalopathy. In tuberculous encephalopathy the following changes have been described. (1) Diffuse oedema of the brain

TUBERCULOUS MENINGITIS IN CHILDREN

(2) Perivascular myelin loss (3) Haemorrhagic leuco-encephalopathy The cause of tuberculous encephalopathy is not known. There are three postulations. (1) Hypersensitivity to proteins liberated by lysed tubercle bacilli. (2) Isoimmunisation. The mycobacterium increases the immune response to an antigenie constituent of brain tissue—some fraction of myelin. (3) It may be a cerebral microangiopathy— necrosis of capillary endothelium with out an inflammatory reaction. The clinical manifestations of tuberculous encephalopathy are a severe non-specific picture of increasing spasticity, convulsions or decerebration and coma. Clinico—pathological correlation of signs and symptoms of TBM (Tandon, 1973)

(1) Meningeal Exudate gives rise to meningeal signs, cranial nerve involve ment and hydrocephalus. (2) Lesions in the brain parenchyma cause alteration of sensorium, seizures, hypothaiamic symptoms, and brain stem disturbances. (3) Arteritis causes vascular obstruction and focal neurologic deficit. (4) Allergy and hypersensitivity cause oedema of the brain. Clinical features : The majority of the cases (75-85 %) are below the age of five years. The peak incidence is in 3-5 years age group. There is preponderance of the disease in boys. The onset of the disease may be acute i.e. within 6 days, subacute or gradual, taking more than three weeks to develop. The clinical manifestations may be grouped into three stages (High, 1975). In stage 1, the symptomatology is nonspecific and diagnosis is difficult to establish. This stage lasts for 1-2 weeks. State 2 is characterised by appearance of definite neurologic signs. This stage also lasts for about two weeks and is followed by stage 3, the stage of coma. This stage lasts for 1-2 weeks. In India it may be prolonged to 1-6 months. The presenting symptoms reported in various series (Udani, 1974, Benakappa, 1975) are fever in 80-90% cases, convulsions in 50-60%, vomiting in 40-45% and altered sensorium in 20-45 %, Other manifestations are recurrent infections, cough, neurologic deficits in the form of quard-

5

riparesis, hemiplegia, monoplegia, and symptoms of raised intracranial tension like headache and vomiting. The important signs at the onset are an altered state of consciousness in a large majority of cases (60-80%), meningeal signs in about 80% cases, neurologic deficit, fundal changes, cranial nerve palsies and hydrocephalus. Various types of paralysis like hemiplegia, quadriplegia, monopiegia and cerebral paraplegia occur at the onset or during the course of the disease. Hemiplegia and quadriplegia occur in about 20% of cases of TBM, monoplegia and cerebral paraplegia are uncommon. Abnormal movements like hemiballismus, tremors, niyoclonic jerks and cerebellar signs occur occasionally (Udani, 1971). After the disease is well established cranial nerve palsies like optic atrophy may occur. The 7th, 3rd, and 6th cranial nerves are involved often but the 12th is rarely involved. About 10% of the patients present with decerebrate spasms and rigidity. Occasional patients have decorticate spasms and rigidity. Rarely, flexor spasms have been described. In children with advanced central nervous disease even after the age of one year there may be reappearance of neonatal reflexes. During or after recovery from the disease there may be Cushing’s syndrome, obesity, diabetes insipidus and excessive sleepiness. Hematemesis may occur at the onset of tuberculous meningitis. Acute gastic ulcers resulting from hypothalamic lesions have been well documented. Autonomic dysfunction like excessive perspiration, abdominal pain and hyperperistalsis occur occasionally (Udani, 1974). Fundus Examination in TBM

Changes in the fundus are seen in a large majority of children suffering from TBM. Intraocular lesions are more frequent than extraocular lesions and have been reported in 30-75% of cases (Saxena, Verma, Thapar, 1976),. The common lesions in order of frequency are papillitis, optic atrophy and papilloedema. Incidence of choroid tubercles is low in the series reported. However, it is of diagnostic value and may be the only clue to the diagnosis of neurotuberculosis. Optic atrophy may sometimes be the only primary manifestation of TBM and in some cases it is reversible, if adequate antituberculous therapy is given in the early stage of the disease. Cranial nerve involvement has been reported in 15-30 % cases. The facial nerve predominated over oculomotor, and abducent nerves in all Ind. J. Tub., Vol. XXVUI, No. 1

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SATYA GUPTA AND KAMLESH CHOPRA

reported series. Fixed dilated pupil as an isolated finding has been reported in 10-25% cases. Frequent fundus examination should be a routine procedure in all cases of TBM as it gives a clue to the diagnosis of TBM. It also gives the prognosis regarding vision whether there is progressive improvement or deterioration.

Hepatic changes in TBM Histopathological alteration of liver is well documented in various types of tuberculosis. Inderjit et al (1974) described histopathological changes in the form of fibroblastic activity and round cell infiltration in 50% cases of TBM studied by them. Benakappa et al (1975) studied 20 cases of TBM in whom biopsy was done. Of these 20% were normal. Fibroblastic activity was seen in 50% cases; 25% had evidence of round cell infiltration, and 5 % had evidence of acute miliary tuberculosis.

tubercles, though rare, are diagnostic of miliary tuberculosis. Cerebrospinal fluid examination may reveal increase in protein, decreased sugar and pleocytosis predominantly of lymphocytes. In fulminant TBM the pleocytosis may be predominantly of the polymorphonuclear type. Cerebrospinal fluid culture for AFB reveals positive cultures in 20-55% of cases. However, a higher isolation rate is reported by the floatation hydrocarbon technique—50-80 % (Benakappa, 1975). Other tests which have been used and found useful in TBM are : Nitroblue Tetrazolium Test (NTT)

Park devised a simple reliable test which differentiates between bacterial and non-bacterial infections. The principle of the test is that during pyogenic infection certain metabolic changes occur in the neutrophils by which they are able to achieve enhanced phagocytosis. The neutrophils would engulf a large amount Electrolyte disturbances in TBM of the nitroblue tetrazolium dye and also reduce In Parekh et al (1974) series 37.5% had it. The percentage of the neutrophils which enhypernatremia and 7.5% had hyponatremia. gulf the dye would be more in active bacterial The chloride levels were low in 60% of the cases. infections as compared to viral and other nonThis is probably due to protracted vomiting pyogenic infections. In fulminant bacterial inor inappropriate secretion of ADH. The CO2 fections the immune mechanism of the body is combining power was abnormal in 37% of supressed and the NTT may be negative. cases—values more than 28 meq/litre. Potassium Chitale et al (1976) found that reduction of levels are not significantly disturbed. The hypernatremia may result from injury to the hypo- nitroblue tetrazolium dye by the neutrophils thalamus in TBM. Doxiadis et al (1954) also was significantly enhanced in patients of pyogefound significant electrolyte disturbances in nic meningitis whereas it was normal in tuberculous meningitis and healthy controls. The their cases of TBM. test may therefore serve as a simple, quick and cheap diagnostic tool to differentiate between Diagnosis of Tuberculous Meningitis these two conditions which may sometimes pose History of fever, headache, vomiting, con- a diagnostic problem. Hence it is a useful advulsions, altered sensorium or neurologic deficit junct to established methods of investigation. should alert the physician to investigate the case for meningitis. History of contact with a case Bromide partition test of tuberculosis is elicited in 10-20% of cases. Walter in 1929 first used unlabelled bromide This history may not be readily communicated as tuberculosis carries a social stigma. Past his- for the bromide partition test. Crooks in 1960 tory of measles and whooping cough may be used labelled bromide. The risk of radiation is minimal. The principle of the test is that TBM elicited in 5-20% of cases. enhances the passage of many substances from Mantoux test is positive in 25-75% of cases blood to CSF. The ratio falls both during the reported by various workers (Bakoo 1969, first polymorph phase of inflammation and the Ramachandran, 1970, Benakappa, 1975). A second lymphocytic phase. The fall in ratio betpositive mantoux test is an induration of more ween the blood and CSF bromide levels depends than 10 mm at 48-72 hours to 1 T.U. of P.P.D. on the extent and severity of TBM. Purshowtam In fulminant meningitis there is anergy to the Rao et al (1978) suggested that the ratio of 1.6 tuberculo-protein. Roentgenographic examina- or lower is diagnostic of TBM but Bharucha et tion of the chest reveals pulmonary tuberculosis al (1980) suggest that this ratio be fixed at 1.99 in 45-80% of cases. Changes in the fundus may so that no case of TBM is missed. Very low levels be seen in a large majority of cases. Choroid of bromide ratio indicate poor prognosis. This

Ind. J. Tab., Vol. XXVIII, No. 1

TUBERCULOUS MENINGITIS IN CHILDREN

test is easy and simple to perform and no untoward reactions have been described.

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tration and traces of factors 4 and 5. In poliomyelitis and encephalitis there is no increase in CSF LDH activity nor altered isoenzyme patterns.

Cerebrospinal fluid glutamic transaminase levels: Brain tissue contains significant amount of glutamic transaminase (GOT) and any injury Hence CSF, LDH isoenzyme separation is to the brain will increase the GOT levels in the of value in diagnosis of tuberculous meningitis cerebrospinal fluid (Fleischer et al 1957). It is even when other evidence is non-contributory postulated that the increase of GOT levels in or CSF is traumatic (Sundravalli et al 1979). the CSF is due to release of the enzyme from the destroyed cells of the nervous tissue and an Cerebrospinal Fluid Proteinogram altered intracellular metabolism in the diseased CSF protein electrophoresis is one of the state. Also anoxis impairs the blood/brain barrier and leads to decreased elimnation of the enzyme tests that may be carried out to differentiate from the cerebrospinal fluid (Mellick et al, 1964). between tubercular and pyogenic meningitis Praharaj et al (1979) estimated cerebrospinal when routine diagnostic methods fail to diffefluid GOT levels in 20 healthy control children rentiate between the two. and 77 cases of meningitis. The mean normal GOT Cerebrospinal fluid electrophoresis in tuberwas 6.47 I.U/L (range 2-13 I.U/L). In TBM the mean levels were slightly more than normal culous meningitis reveals (Phadke 1975, Sundraas compared to pyogenic meningitis where the valli 1979): levels were much higher. The levels came to 1. Higher proportion of gammaglobulin normal values as patients improved. Prognosis does not depend on the initial cerebrospinal than betaglobulin. In pyogenic meningitis and in normal CSF betaglobulin is higher than fluid GOT levels. gammaglobulin. Similar findings have been reported by other 2. Alpha1 -globulin is more than alpha2 investigators. Cerebrospinal fluid glutamic pyruglobulin. In normal CSF and in pyogenic menvic transaminase (GPT) is also reported to be ingitis the reverse is true. higher than normal. (Normal means 13 I.U/L) Serum and cerebrospinal fluid magnesium It was the classical observation of Cohen (1927) that cerebrospinal fluid magnesium was higher than the respective serum values. In tubercular meningitis the cerebrospinal fluid magnesium tends to approximate plasma values. This has been corroborated by other workers (Mishra 1973, Rajvanshi 1970). There is an association of hypomagnesia with a longer duration of illness and it carries a poor prognosis especially when associated with an advanced stage of illness. There is an inverse relation of cerebrospinal magnesium with cerebrospinal fluid protein and cells, whereas it correlates directly with CSF sugar. The symptoms produced by magnesium depletion are difficult to determine (Ahmad et al 1977) Lactate Dehydrogenase Isoenzymes (LDH) (1) LDH activity is raised in pyogenic meningitis, tuberculous meningitis and in new borns. (2) Isoenzyme patterns show an abnormal increase in factor 3 in tuberculous meningitis and factor 5 in pyogenic meningitis. In traumatic CSF the LDH is high because of the presence of LDH in the blood. The isoenzyme separation will reveal LDH 1,2,3 in equal concen-

Minimum Diagnostic Criteria The cerebrospinal fluid examination reveals raised proteins with low sugar and pleocytosts predominantly of lymphocytes along with the history and clinical picture. Presence of extracranial tuberculosis is corroborative evidence. In cases of tuberculous encephalopathy the CSF is normal and the clinical picture is of diffuse cerebral involvement resulting in convulsions, increasing spasticity, coma and in advanced stages, decorticate or decerebrate spasms or rigidity. There may be abnormal movements, hemiplegia, quadriplegia, evidence of raised intracranial tension but there are no meningeal signs. Diagnosis can be suspected if a child with miliary, disseminated or intrathpracic tuberculosis develops signs of diffuse brain involvement but there are no meningeal signs and the CSF is normal or shows mild increase of protein or cells, Treatment : The success in the management of tuberculous meningitis depends to a great extent on the prompt diagnosis of the disease. However because of the protean manifestations the diagnosis can pose a diagnostic dilemma. There are no direct laboratory methods for quick diagnosis. There has been no significant

Ind. J. Tub., Vol. XXVIII, No. 1

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SATYA GUPTA AND KAMLESH CHOPRA

reduction in mortality even after the introduction of new effective anti-tuberculous drugs and the mortality is directly dependent on the state of consciousness at initiation of therapy. The choice of antibacterial drugs depends on (1) Ability to penetrate the meninges. (2) Bactericidal activity. (3) Potency. (4) Toxicity.

(5) Cost of therapy.

Isoniazid is mainstay of chemotherapy because of (1) Excellent penetration into the cerebrospinal fluid. (2) Low toxicity, (3) Bactericidal activity. Usual dose is 20 mg/kg/day subject to a maximum of 30Qmg/day. Streptomycin and ethambutol penetrate only when the meninges are inflamed. Hence they should be used only in the first 6-8 weeks of therapy. Dose of streptomycin is 40 mg/kg of body weight/24 hours; maximum 1 gram/day given as a single intra muscular injection. Ethambutol dose is 25-45 mg/kg/day the higher dosage being more likely to produce effective concentration. If used for 6-8 weeks it is unlikely to produce optic neuritis. Besides, it is reversible on stoppage of the drug and no long term complications have been described. Rifampicin

The concentration of the drug is lower in the CSF than the blood, though penetration of the meninges is increased during inflammation. The concentration of the drug is slightly more than the minimum inhibitory concentration for tubercle bacilli, Usual dose is 10 mg/kg/body weight, maximum 600mg/day given once daily on empty stomach. Various combinations are used in the treatment of tuberculous meningitis. The combination of Streptomycin, Isoniazid, Ethambutol and Prednisolone is a regimen of low toxicity but the bactericidal activity is less than the combination of Streptomycin, Isoniazid and Rifampicin. This regimen is bactericidal and it is effective in the presence of Isoniazid resistant organisms. Rifampicin resistant strains of tubercle bacilli are rare. If there is a known contact with a patient excreting drug resistant organisms, then Pyrazinamide may be added to the regimen of Streptomycin, Isoniazid and Rifampicin. Pyrazinamide and Streptomycin are given for Ind. J. Tub., Vol. XXVIII, No. 1

the first 6-8 weeks of therapy. Therapy is continued with Rifampicin and Isoniazid for a further 4-6 months and finally treatment completed with a few months of isoniazid alone. The combination of Streptomycin, Isoniazid, Rifampicin and Pyrazinamide is the best bactericidal regimen but there is risk of hepatotoxicity. Besides this, the cost of therapy is high. Cost of drugs like Rifampicin, Ethambutol and Pyrazinamide makes them inappropriate for use for sensitive strains of mycobacterium tuberculosis which comprise about 90 % of the isolates. Streptomycin and Isoniazid are effective in the treatment of TBM caused by strains of mycobacterium tuberculosis sensitive to them. The schedule followed by us in the treatment of TBM is Streptomycin 40mg/kg/day, maximum 1 gram/day given as a single intramascular injection, Isoniazid 20mg/kg/day (maximum 300mg/day) as a single dose and Ethambutol 25mg/kg/day given for 3 months. Prednisolone 2mg/kg/day is given for an initial period of 6-8 weeks. After3 months, Isoniazid 20mg/kg/day and thiacetazone 3-5 mg/kg/day are continued for 18-24 months. Rifampicin has not proved very valuable because of the high incidence of jaundice in our cases. The mortality appears to have been reduced considerably after the introduction of ethambutol to the schedule. Adrenocorticosteroids should be added to the therapeutic regimen in patients of tuberculous meningitis. The treatment of cerebral oedema has improved survival and thus administration of corticosteroids in high dosage is clearly indicated in the management of cerebral oedema (Kapur, 1969). Besides, steroids reduce the spinal block, decrease CSF protein and pleocytosis besides depressing the tuberculin hypersensitivity, suggesting that inflammation particularly that dependent on tubercular hypersensitivity is reduced. However reports on the efficacy of corticosteroids in tuberculous meningitis are conflicting. Ghosh (1974) found no beneficial effect in controlled trials. Besides specific therapy, supportive therapy is very important. Maintenance of fluid and electrolyte balance, adequate nutrition, early detection and treatment of inter-current infection, use of anti-convulsant therapy, treatment of hyperpyrexia and care of the skin, bowel and bladder are all contributory. Medical management of cerebral oedema.

The drugs most frequently used in the emergency treatment of cerebral oedema are mannitol and urea. These drugs act rapidly. The dose

TUBERCULOUS MENINGITIS IN CHILDREN

of manmtol (20 %) is 1.5-2 gm/kg. It is administered every 6-8 hours intravenously. The onset of action is between 20-30 minutes. The peak action lasts for 30-60 minutes and the duration of action is for 3-8 hours. The dose of urea (30%) is 1.0-1.5 gm/kg. It is given every 6-8 hours intravenously, the onset of action is within 10 minutes, the peak action lasts for 20-30 minutes and the duration of action is for 2-6 hours. Repeated admistration of the hypertonic agents, however, causes fluid and electrolyte imbalance with a secondary increase in intracranial pressure (the rebound phenomenon) and also they potentiate intracranial bleeding. Hence these drugs should be used for the first 48-72 hours of therapy only. Corticosteroids act more slowly than the hyperosmolar agents. Besides this, they can be used for prolonged periods without causing secondary rebound effect or intracranial bleeding. The dose of dexamethasone is 0.2-0.4 mg/kg given every 6 hours intravenously. The onset of action is after 12-18 hours, the peak action lasts for 12-24 hours and the duration of action is for several hours.

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and improvement in level of consciousness occurred in most of the cases. Stretching of vessels by dilated ventricles may be responsible for narrowing of arteries and reduction of blood flow. The resultant ischemia is responsible for reversible aphasia, hemiparesis and blindness. The procedure should be carried out at an early stage before irreversible damage occurs. The insertion can be made during an active stage of the disease without much fear of dissemination of the disease. Septicemia in a few cases has been reported after shunt operation. Factors Influenceng Prognosis of Tuberculous Meningitis

The various factors influencing mortality and morbidity in terms of neurological damage are primarily the stage of the disease in which the treatment is started. Highest mortality as well as neurological damage occur in stage 3 of the disease.

Glycerol can also be used for chronic treatment of raised intracranial pressure. The dose of glycerol is 0.5-1 5 gm/kg, every 4-6 hours intravenously (10% solution) or orally. The onset of action is within 30 minutes. The action lasts for 24-48 hours.

Dikshit et al (1976) reported 70% mortality and 74% neurological damage in stage 3 as compared to 22% mortality and 11% neurological damage in stage I of the disease. The neurologic damage was maximum in children below 3 years of age and optic atrophy occured in a large majority of cases.

Acetazolidine may also be used to decrease the raised intracranial tension. It decreases CSF production. The dose is 25—30 mg/kg given orally in 2—3 divided doses,

The mortality in malnourished children was higher than in the well-nourished group, 92% and 34% respectively.

Surgical Management of Raised Intracranial tension:

The neurologic damage is significantly enhanced in children whose duration of disease is more than one month.

The raised intracranial pressure is an important factor adversely affecting the course of the disease. In the acute stage, cerebral oedema is due to three factors—inflammation, tuberculoprotein allergy and increased permeability of the vessels. In the subacute and chronic stages of the disease, internal hydrocephalus due to basal adhesions causes increased intracranial pressure. Hydrocephalus is due to the exudate and adhesions in basal cisterns and obstruction of foramina of Luschka and Magendie, narrowing of aqueduct of Sylvius or poor absorption of CSF from cerebral cortex. Insertion of ventriculoatrial shunt in patients with dilated ventricular system will reduce the raised intracranial pressure. Bhagwati (1974) performed shunt operation in 24 cases of TBM with hydrocephalus. Following reduction of intracranial pressure a considerable regression of neurological deficit

The high mortality and neurologic damage in children of low socio-economic status is probably due to malnutrition, overcrowded living conditions, ignorance, illiteracy, poverty and failure to get prompt and adequate therapy. Antecedent infections like measles and pertussis have an adverse influence probably because of the depressed immunological status and rapid dissemination of infection. The educational status of the family and the importance of realising that regular and prolonged therapy are essential to reduce the neurological damage are significant factors which influence the mortality and neurologic damage from TBM.

Ind. J. Tub. Vol. XXVIII, No, 1

10

SATYA GUPTA AND KAMLESH CHOPRA

Mortality and Sequelae

Fikrig, S. M. et al (1973): NET dye test and differential diagnosis of meningitis. J. Pediat. 82: 855.

The mortality in TBM is 15-75% as reported by various workers (Sur 1959, Khatua Fleisher C. A., et al (1957): GOT and lactic dehydrogenase in serum and CSF of patients with neurologic 1961, Udani, 1970, Benakappa, 1975). Adverse disorders, Proc. Mayo, Clinic 32; 188. sequelae occur in 10-85 %of cases (Ramachandran 1970, Udani, 1974). They are mental retardation, epilepsy, neurological deficit in the form of Ghosh, S. (1974): Evaluation of corticosteroids as an adjuvant in the treatment of tuberculous meningitis. hemiplegia, quadriplegia, cranial nerve palsy Symposium on tuberculosis of the nervous system (commonly 7th, 3rd and 6th cranial nerves), (WHO & 1AMS) 137. blindness, deafness, behaviour problems, hydrocephalus, hypothalamic disturbances in the form of precocious puberty and diabetes insipidus. Gupta C. K., et al (1975), Nitroblue tetrazolium dye test in septic meningitis. Ind., J. Med. Re. 63: 266.

REFERENCES Ahmad A.J., et al. (1977): Serum and cerebrospinal fluid magnesium—a prognostic index in tubercular meningitis Ind. Pediat. 14-467. Benakappa D., et al (1975): Tuberculous Meningitis: Review of 50 cases. Indian pediatr. 12, 1161. Bhagwati, S. N. 1974, Ventriculo—atrial shunt in the treatment of Tuberculous Meningitis. Symposium on tuberculosis of the nervous system (WHO/IAMS) Pp. 77. Bhakoo O. N. and Gupta S. P. (1969): Tuberculosis in children. Indian Pediatr. 36 .: 65. Bharucha, P.E. et al (1980): The 82 Br. Test in the diagnosis of tuberculous meningitis: Indian Pediat. 17:65. Bharucha P. E., Talwalkar, Y. B. (1962) Treatment of tuberculous meningitis. Ind. J. Ch. Hlth. 11-101. Bhatnagar, B. S. and Srivastava, B. N. (1961) : Ocular changes in tuberculous meningitis in children; a preliminary report on 30 patients. (Ind. J. Med. Sc. 15 966,) Chitale, M. S. et al (1976): Tetrazolium test in tuberculous and pyogenic meningitis. Ind. Pediat 13:447. Cohen H. (1927) The magnesium content of cerebrospinal fluid and other body fluids. Quart. J. Med. 20: 173. Dastur. D. K., Lalithe V. S. (1973): The many facets of neurotuberculosis: Progress in neurotuberculosis Ed. Zimmerman, Grune and Stratton. New York and London. Page 351. Dikshit K. P., Surendra Singh (1976): Factors influencing prognosis of TBM. 13: 613. Doxiadis, S. A., et al, (1954) Electrolyte imbalances in tuberculous meningitis. B. M. J. 1; 1406.

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High R. H. Nelson, W. (1975) Text book of Pediatrics, 10th edition Saunders. Philadelphia, London Pp.639. Inderjit S. et al (1974): Hepatic involvement in childhood tuberculosis. Indian Pediatr. 11:171, Indian Council of Medical Research (1958). Tuberculosis in India. A sample survey 1955-1958, Special series 34: New Delhi, ICMR. Kapur, S. (1969): Evaluation of treatment of tuberculous meningitis since the use of steroids as an adjuvant, Ind. Pediatr. 6:166. Khatua S. P. (1961): Tuberculous meningitis in children. Analysis of 231 cases; J. Indian Med. Ass. 37: 332. Magotra, M. L. et al (1974): Pulmonary tuberculosis: Review of 300 cases. Indian. Pediatr. 11:529. Mellick, R. S. Bassett R. S. : (1964) CSF GOT activity in Neurologic diseases. Lancet 1: 904. Mishra, P. K, et al (1973) Magnesium in meningitis: Ind. Ped. 10: 32. Mishra R. K., Gupta S. P. (1962) Ocular complications of tuberculous meningitis. Jour. Ind. Med. Ass. 38: 513, Mooney, A. J. (1956): Some ocular sequelae of tuberculous meningitis; Amer J. Ophth. 41 : 753. Parekh U. et al (1974): Serum Electrolytes in Tuberculous Meningitis, Symposium on Tuberculosis of the nervous system sponsored by W. H. O. and IAP, 27 Padhake, M. A. et al (1975): CSF electrophoretic proteinograms in tuberculous and pyogenic meningitis. Indian Pediat, 12 : M69. Praharaj, S. C. (1979): Cerebrospinal fluid glutamic oxaloacetic transaminase level in tuberculous and pyogenic meningitis in children; 14 : 673.

TUBERCULOUS MENINGITIS IN CHILDREN

Purshowtam Rao et all (1970): Bromide Partition test. Ind. Pediat. 15 : 485, Raj Narain, (1963): Some aspects of tuberculosis prevalence survey in South Indian Districts. Bull. WHO 29 : 641. Rajvanshi, V. S. et al (1970) : Serum Magnesium level in some common disorders. Ind. Pediat. 7: 502. Ramachandran, R. S. (1968): Tuberculosis in children: Experience with 1,284 cases. Indian Pediatr. 5: 564. Ramachandran R. S. (1970): Tuberculous meningitis Ind. Jr. Pediat. 37 : 85. Rao K. N. (1972) Text book of Tuberculosis, First Edition Kothari Book Depot. 339. Saxena S., Tomar, V, P. : (1976) Ocular lesions in tubercular meningitis Ind. Ped. - 7 : 622. Sharma, P. N. et al (1974) : A study of tubercular meningitis in children. Symposium on tuberculosis of the nervous system (WHO/IAMS) J57.

11

Tandon P. N., Pathak S. N. (1973): Tuberculous meningitis in tropical neurology (Ed. J. N. Spillane), Oxford University Press. New York, Toronto 41. Thapar, R. K. et. al. (1968): Ocular manifestations in tuberculous meningitis. Ind. Ped. 5 : 465. Udani, P. M. Bhat U. S. (1974): Tuberculosis of central nervous system, Part II: Clinical aspects, Ind. Pediat. 11 :7. Udani, P. M. et al (1970): Tuberculosis of central nervous system; incidence and classification; Indian Pediatr. 10 : 647. Udani P. M. et al- (1971): Neurological and related syndromes in CNS Tuberculosis-Clinical features and pathogenesis: J. Neurol. Sci. 14 : 341. Udani P. M. et al (1974): Neurological and related syndromes in neuro-tuberculosis in children with further observations. Tuberculosis of the nervous systemMonograph on the Proceedings of the Symposium sponsored by WHO and Indian Academy of Medical Sciences. 37.

Sundravalli N, (1979): Polyacryalmine gel electrophoretic studies of cerebrospinal fluid proteins and lactic dehydrogenase isoenzymes in tuberculous meningitis and certain neurological disorders 16 : 15.

Verma, B. M., Agrawal, V. K. (1966): Ocular manifestations of tuberculous meningitis in children-A clinical study. Ind. Ped. 3 : 187.

Sur Am et al (1959): Tuberculous meningitis, Indian. Jr. Child Health 8 : 281.

Whytt, R. (1768): Observations on the Dropsy in the Brain, Balfour, Auld & Smelle, Edinburgh 24.

Ind. J. Tub., Vol. XXVIII, No. 1

TUBERCULOSIS CASE-FINDING AMONG SYMPTOMATICS IN THE COMMUNITY —A REAPPRAISAL

A.K. CHAKRABORTY* Summary: The anti-tuberculosis programme for case-finding from among self reporting symptomatic patients at the general health facilities is found to diagnose only about 600-650 cases of pulmonary tuberculosis as against the potential of about 2,000. The reasons for shortfall could be the relative lack of urgency about cough among suffering persons in the community especially among the elderly male patients forming the biggest reservoir of cases, preference to indigenous medical practitioners, private practitioners and quacks over the Government dispensaries by those who seek action and distance of the Government dispensary from villages. The scheme of Multipurpose Workers (MPW) visiting patients in their homes in the villages can remedy the above lacunae. It is shown to be simple. Preparation of sputum smears and their despatch to examination centres are found feasible.

Rationale of DTP

Tuberculosis is one of the major health problems in India and 80 % of the patients are distributed in the rural areas, with almost similar prevalence rates in different parts of the country. The District Tuberculosis Programme (DTP), as evolved at the National Tuberculosis Institute (NTI) (Nagpaul, 1967) was accepted by the Government and its implementation started in 1962. Its aim is to tackle the problem of tuberculosis adequately and within the available resources by setting up diagnostic and treatment services for tuberculosis in the general dispensaries distributed throughout the district, under the management and supervision of the district centre (DTC). The finding of Banerji and Andersen (1963) that of the total tuberculosis patients in a community at any point, about half attend any of the Government general health institutions, is a significant finding in support of the DTP. The other significant findings in this regard are that (i) it is possible to diagnose about 80 percent of all the sputum positive cases (“Cases”) reporting to the general health institutions by resorting to microscopy only : in other words 40% of the point prevalence of cases in the community can be diagnosed (Baily, Savic et al, 1967) (ii) microscopy is cheap and convenient to perform at the general health institutions, and (iii) for the above activity, no additional appointments at participating health institutions are to be made whereas only marginal increase in workload on their staff is envisaged and no costly equipment is required. Thus, the DTP is based on people’s demand, need and the ability to thrive on the meagre resources of the health services. It is envisaged that if the DTP is implemented in all of the nearly 50 general dispensaries in an average district in India, each with a daily attendance of 50 persons on an average, and

they examine at least one slide a day from voluntarily attending symptomatic persons, it would amount to the diagnosis of nearly 2,000 cases (Baify, Savic et al, 1967), which is quite good potential, considering the fact that there are about 5,000 cases in the district at any point of time. The number of cases diagnosed however would vary with the number of PHIs where the DTP is actually implemented. It has, however, been realised lately that the DTP has never achieved the above potential so that in actual fact, on an average, about 600 to 650 cases are being diagnosed by DTP in a year (NTI, 1979). One reason for this shortfall is that the number of PHIs implemented per DTP has been, on an average, about 34 for the entire country (NTI, 1980), instead of 50 as envisaged above. Apart from that, people, their health and health services form a complex- phenomenon which needs more probing, so that contributory causes for observed shortfall can be removed or minimised. Programme corrections can also be effected if the situation so demands. In the following paragraphs some of the relevant research findings and their interpretations are presented to investigate possible lacunae and corrective actions to improve the DTP. Symptoms and their Significance

It is well known that the community does not necessarily view its sufferings in the same light and with the same urgency and seriousness as a health professional would like it to do on the basis of his observations and epidemiological quantifications. The following study makes the point, wherein it is measured that on a single day, 60% of the total sickness prevalent in a community comprised of only three symptoms (Nagpaul, Baily et al, 1977). These were, in order of their occurrence : cough, pain of all kinds and fever. Loose motions & some other symptoms formed a small minority. However, on the same day, study of the attendance pattern

*Senior Medical Officer, National Tuberculosis Institute, Bangalore 560 003.

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TUBERCULOSIS CASE-FINDING AMONG SYMPTOMATICS IN THE COMMUNITY

at the out-patient department (OPD) of the primary health centre (PHC) of the area revealed the order of the symptoms among those who attended it, to be: pain, fever and cough. Loose motions accounted for a much higher attendance than could be expected from its prevalence in the community on that day. It could be inferred that measurement of the sickness in the community may not be so crucial in deciding the nature and type of facilities and equipment to be made available at the area health centre. The example of cough as a symptom in the community can be further illustrative of the difference in perception of the respective importance of symptoms by the community as compared to that by the health services. Prevalence of chest symptomatics of 7 days or more duration in the community is about 11%; about1.6% of such symptomatics are A likely to be tuberculosis cases (Radha Narayan, Thomas et al, 1976). For success of case finding under DTP, attendance at the Government dispensaries of these chest symptomatics, being the most important reservoir group of tuberculosis cases, is considered a key factor by the antituberculosis programme planners. Persuaded by their symptoms, about half the tuberculosis cases in the community, as stated earlier, seek action on their own at a point and the other half do not (Banerji & Andersen, 1963). The DTP is designed to cater to the first group only, and is virtually silent in respect of the latter. Perhaps it is envisaged that if the actiontaking half is satisfied with the service provided to them at the dispensaries they attend, the group not taking action would also be encour aged to attend these in due course. Hence, it is thought that the DTP will bring into being a snow-ball effect, satisfied customers generating fresh streams of other customers. This unfortunately is yet to happen. Continued lack of uti lisation of PHC by cough patients is a testimony to that. One very pertinent fact not often realised or presented adequately is that whereas about half of the chest symptomatics do not take action, the other half who really do so, do not seem to choose the governmental agencies alone for the purpose. It is seen from the table pre sented below (Radha Narayan, Thomas, et al, 1976) that nearly half the chest symptomatics (47.7%) take action to get diagnosis and/or treatment, but only 22% attend the Government hospital and rural health facilities for the purpose (Table 1). Others find their way to the private doctors or resort to ‘pooja’ (religious rites) or Ayurveda etc. It is not that such behaviour is peculiar to chest symptomatics only. It applies to all symptomatics. Hence, stepping up

13

of diagnostic facility at the Government health agencies alone, as has been generally attempted under the DTP, only means that the DTP is not able, even by design, to cover the actiontaking half of the symptomatics in the community. Table I Action taking by chest symptomatics and others as per health facilities attended by them {Radha Narayan,

Thomas et al, 1976)

It appears from the findings reviewed above that though Government health facilities are preferred by the actual cases of tuberculosis in the community more than other health facilities, the leading symptom of cough seems to be accorded a less importance by the community compared to some other illnesses as judged by their attendance pattern at health facilities. By catering only to symptomatics visiting the Government health facilities, a large group of symptomatics may not be contacted by the health services. No chances seem to exist to wean them away from the quacks or profit motivated agencies at large. Their participation in health programmes, though desirable from the point of view of their success, remains largely unrealised. Linking reservoir in community with registered disease at dispensaries In the figure below, the age-wise proportional distribution of population aged 10 years and over and the percentage distribution of the total tuberculosis cases by age in the community are presented. It depicts a well known epidemiological finding that nearly half of the tuberculosis cases are to be found in the population aged 40 years and over (Gothi, Ind. J. Tub., Vol XXVIII, No. 1

14

Chakraborty et al, 1979), However, the significant point to be noted is that sick persons aged 45 years and over attend PHCs less than expected or warranted by the higher prevalence of tuberculosis cases in these (Nagpaul, Baily et al, 1977). It could also be seen in the figure that relatively smaller proportion of population, that is males aged 60 years and more (5.3%) (Gothi, Chakraborty et al 1979), would contain 23.6% of all the tuberculosis cases in the community. On the other hand if the pattern of diagnosis in the O.P.Ds is studied, only 4.5% of all the tuberculosis cases diagnosed there, are among males in age group 40 years and over, and only 4.5% are among males aged 60 years and over (Nagpaul, Vishwanath et al, 1970). In other words if OPD diagnosis is considered, the tuberculosis cases diagnosed are not so much in the elderly male population as they should be, since prevalence of cases is remarkably high among them. It is clear from the above that the two major reservoir groups from the point of view of tuberculosis control, namely, patients with cough and aged male tuberculosis cases, have less than desired attendance at the PHC. The decision to seek relief is obviously not related to suffering alone : tuberculosis cases younger in age attend the health facilities more either because they are more health conscious or because of their higher economic worth to the family. But from the disease control point of view, the priority is different. Reduction of the

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transmitters might take place to a substantial extent, if only substantial proportion of the target population of transmitters, attend the PHC making them amenable to diagnosis and treatment, which unfortunately is not being achieved in reality. Less than expected attendance is not confined to the elderly tuberculosis cases, or patients with cough only but it appears that the observation is applicable, to some extent, to all sick persons in the community. This is evident from the observation (Nagpaul, Baily et al, 1977) that on any day nearly 10% of the total population in the villages are sick with something or other, though a mere one percent of those sick take the trouble of reporting at the respective PHC. It cannot be due to the reaction of the community to the supposed lack of expertise or that of high quality of service offered at the PHC. Relatively, even meagre utilisation by the community of the services provided by the specialised agencies, located at some distance from their homes is a phenomenon only too well known. Thus it is reported that (Baily, Savic et al, 1967) of the 724 symptomatics in a rural centre referred to specialised district centre for an X-ray chest, only 55 went for it and returned to know the result also. It has further been shown that in a city area patients utilised the services near their homes more than at the specialised centre. The above could be interpreted either as a

TUBERCULOSIS CASE-FINDING AMONG SYMPTOMATICS IN THE COMMUNITY

lack of awareness of suffering or of condfidence of sick persons in the services not constantly available in their midst or as reluctance of the sick to travellong distances to obtain medical care; or may be, both. In fact, the effect of distance is very great on the chances of the community availing of the health service facility. It is found (Nagpaul, Baily et at, 1977) that very few sick persons from beyond a 5 km walking distance in villages would attend a PHC; and of the total PHC attendance on a day, 40% is derived from the PHC village itself. In a study by Nagpaul et al, 6.4 km emerged to be the key threshold for the cities beyond which attendance even at the specialised centres were inappreciable (Nagpaul, Vishwanath et al 1970). All this means that more and more facilities are needed to be created as near to the patients’ homes as possible; patients won’t unduly bother about the degree of sophistication available in these facilities. Health care close to patients’ home : Rationale of MPWs scheme The acceptance, almost preference, of patients for health institutions near their homes led to the importance of health programmes emanating from the rural PHC and the subcentres. The Government’s policy of continuously trying to expand the sub-centre facilities and progressively equipping these adequately are, no doubt, on sound lines. However, the subcentres cannot be located at every village in the country, and the farther a centre is from a village, lesser is the chance of its utilisation by the villagers. This brings in the need for contacting sick persons at their homes. The outreach of the PHCs and sub-centres has to be extended far beyond these. In the past, MCH workers, malaria workers, community development extension workers etc have been visiting the patients/villagers at their homes, In the case of tuberculosis case-finding also, the yield of cases, detected by community development workers visiting symptomatics from house to house in villages, was found comparable to any other case-finding method (Chakraborty and Gothi, National Tuberculosis Institute, 1979). Thus, in case permanent workers are available who would visit villagers at their homes regularly an effective case-finding service can be provided to the community on a constant on-going basis by such workers. It is however, preferable on several operational grounds to have multipurpose health personnel, for visiting the villages, instead of unipurpose specialised workers. Regular and periodic contact, between the population and the health auxiliaries has been accepted as the

15

basis of the integrated Multi-purpose Workers Scheme (Government of India, 1979) of today (MPW Scheme). Under the MPW scheme, the MPWs in their allotted villages are required to visit each house systematically and regularly and carry out collection of blood slides from fever cases, treatment of minor illness, immunization, vaccination of eligibles, chlorination of village wells and referral of more seriously ill patients, to mention but a few of their more important tasks. If questioning for chest symtoms and collection of sputa from symptomatics are included as their legitimate tasks as well, it would go a long way in correcting some of the observed deficiencies of the antituberculosis programme planning as well as in satisfying the needs of the individual patients. It can no doubt be argued that services provided at the door steps of the people would decrease the responsibility of the people to their own sickness, ultimately making them more dependent on ready-made solutions to their problems, thereby decreasing their attendance at official health facilities. Available data from a recent study (Aneja, Menon et al, 1980) appear to be contrary to this hypothesis. It is shown (Table 2) that the detection of tuberculosis cases even at the OPD of the PHC from among the voluntarily attending chest symptomatics there, went up considerably in the PHCs, where a scheme of contacting patients at their home in the villages through the MPW Scheme was Table II Tuberculosis cases found at the OPDs of PHCs and the MPWs in villages in a research study (in 4 months) (Aneja, Menon et al 1980)

16

A.K. CHAKRABORTY

slides of adequate standard in the field, unsupervised by anybody (Aneja, Menon et al, 1980). Further, very few were lost in transit. In this study, only the routine channels of despatch as used for malaria blood slides, were adopted by the MPWs for the despatch of Simplicity : Prerequisite of MPWs tasks sputum slides as well, and these were satisfacIt must be kept in mind in this connection, tory. Thus it is reasonable to expect that sympthat two of the most important requirements of tom questioning, sputum slide making and their the tasks to be performed by the MPWs are despatch are not likely to present considerable that these should be simple and less time con- problems to the field workers. suming. Speed in performing the tasks allotted to them can only be achieved by simplification Conclusion of techniques and procedures. The results of A reappraisal of some of the epidemiological studies carried out at the NTI (Banerji and Andersen, 1963) have demonstrated that symp- characteristics of tuberculosis, of population tom elicitation for finding cases of tuberculosis behaviour in respect of suffering and the relief need not be a detailed time-consuming procedure. providing agencies in the community has become It has been shown (Table 3) that cough, alone inevitable in the wake of general realisation that or in combination, is present in 69.4% of the the latter are not performing as per expectations tuberculosis cases. Moreover, none of the cases vis-a-vis anti-tuberculosis programme. The seem to have any other symptom alone. On the Indian Council of Medical Research Expert other hand, very few of the others i.e. the “non- Committee (ICMR, 1979), while agreeing with cases” (9.4%) have the symptom of cough. the soundness of the rationale of the DTP the inadequacy of the anti-tuberculoThe above study on pre-eminence of cough finds observed sis programme activity at general dispensaries. its corroboration in a separate study (Gothi, A recent study in the Tumkur District (ChannaRadha Narayan et al, 1976), which singled out basaiah and Chakraborty, 1979) pointed out that cough as the one symptom present in tuber- the casefinding activity as carried out under culosis cases without fail. Hence, MPWs in the the DTP is far short of expectations. The possible course of their routine rounds could question causes for this may He as much in the population the population for the symptom of cough behaviour toward their suffering as in the effialone. This has considerably simplified the task ciency of general health agencies. for the MPWs without, at the same time, reducing the case yield. Following observations of inadequacy in the provision of general health care to the rural Table III population, Government of India formulated sometime back, the MPWs scheme, which is Nature of Symptoms in Tuberculosis Cases (Banerji & currently being implemented on a country-wide Andersen, 1963) basis. The MPWs Scheme has sought to expand the outreach of the primary health centres to the village community in a broad-based manner. It is designed specifically to answer many of the problems that are faced in the provision of health care to meet the needs and demands of people, viz., multiplicity of uni-purpose workers unconvincing!y presenting their respective programme to the community often giving them an impression of conflicting and competitive rather than complementary interest in the process; inadequate and indifferent services often provided at the institutions themselves and their inappropriate and insufficient geographical distribution and finally the lack of utilisation by the population of whatever services are made available there.

being tried. However, the validity of these findings over a longer period of observation and under conditions of an actual service programme is yet to be established.

*Other symptoms: Haemoptysis, chest pain, fever

The second task for MPWs in TB programme is the sputum collection and despatch. A recent study has conclusively shown that after only two days training, MPWs could make sputum

Ind. J. Tub., Vol. XXVIII, No. 1

Studies carried out by this Institute point out that, by and large, a programme of tuberculosis case-finding operating through the clinics and general dispensaries also suffers

TUBERCULOSIS CASE-FINDING AMONG SYMPTOMATICS IN THE COMMUNITY

from the aforesaid limitations, which are essentially similar in nature to those experienced by the general health services for providing general health care. Hence, if the MPWs Scheme succeeds in providing better health care in the villages in an integrated manner, it is also logically expected to rectify, to an appreciable extent, the observed deficiencies in the tuberculosis casefinding programme operating through the general health intuitions. The NTI study reported by Chakraborty and Gothi (1979) had established the potential of case-finding carried out through the permanent community development workers visiting the homes in the villages and found its yield to be adequate and comparable to that of any other method of case-finding. However, at the time the study was carried out such agencies were not in operation on permanent and regular basis in the rural areas. To freshly create such an army of workers was beyond the bounds of possibility at that time. Hence, case-finding was restricted only at the health institutions, recognising thereby the importance of the state of development of health infrastructure in influencing the course of health planning. No alternative was in sight for long thereafter, inspite of the observed deficiencies, some of which are outlined in this paper. However, as the MPWs Scheme is being implemented today and as tuberculosis case-finding by utilising the services of MPWs appears feasible. Administrative actions to bring tuberculosis case-finding within the purview of the MPWs regular work schedule are already in hand. A widely disseminated permanent programme necessary for tuberculosis control can only be provided by the fairly wide spread general health services. The MPWs Scheme with the objective of extending general health care of rural areas seems to satisfy the requirements of an anti-tuberculosis programme admirably. Much, of course, depends, as in the case of any other programme, on whether the MPWs programme will be run on efficient lines or not ! Acknowledgement

The author thanks Dr A. Banerji, Director-in-charge for permission to publish the

17

paper; Miss K.R. Prameela and Mr. P. Perumal for secretarial assistance and Messrs Hardan Singh, Statistician & B.R. Narayana Prasad for assistance in drawing the figure. REFERENCES Aneja K.S., Menon N.K., Chakraborty A.K., Srikantan K, Manjunath (1980) Under Publication. Daily G.V.J., Savic D., Gothi G.D., Naidu V.B. & Nair S.S. (1967) Bull. Wkl. Hlth. Org. 37, 875. Banerji D. & Andersen S. (1963) Bull. Wld, Hlth. Org. 29, 665. Chakraborty A,K., Gothi G.D. (NT1, Bangalore (1979) Ind. J. Tuberc. 26, 26. Chanrmbasavaiah R & Chakraborty A.K., (1979) J. Com. Dis. 1 1 , 101. Gothi G.D., Radha Narayan, Nair S.S., Chakraborty A.K., Srikantaramu N. (1976) Ind. J. Med. PCS . 64, 1150 Gothi G.D., Chakraborty A.K., Nair S.S., Ganapathy K.T. & Banerjee G.C. (1979) Ind. J. Tuberc. 26, 121. Government of India (1977) National Plan for Health Care Services in the Rural Area, NIHAE Bulletin 19, 134. Indian Council of Medical Research (1976) Unpublished data. Nagpaul D.R., (1967) Ind. J. Tuberc. 14, 186. Nagpaul D.R., Vishwanath M.K., Dwarakanath G. (1970) Bull. Wld. Hlth. Org. 43, 17. Nagpaul D.R., Baily G.V.J., Prakash M. & Samuel R. (1977) Indian J. Med. Res. 66, 635. Narayan R., Thomas S., Pramila Kumari S., Prabhakar S., Ramaprakash N., Suresh T. & Srikantaramu N. (1976) Ind. J. Tuberc., 23, 160. NTI, NTP 3rd Quarterly Report 1979 (1978) NTJ News Letter 16, 63. NTI (1980) Report on NTI for the quarter Nov-Dec. 1979 (unpublished).

Ind. J. Tub., Vol. XXVIIl, No. 1

TUBERCULAR BACILLURIA-A CLINICO-BACTERIOLOGICAL STUDY S.K. AGARWAL*, V.K. SRIVASTAVA* and R. PRASAD* Summary : A total of HO urine samples collected from patients of pulmonary tuberculosis and 100 urine samples from healthy individuals seeded artificially with Mycobacterium tuberculosis Var. hominis (H 37 RV) in different dilutions were studied. A total of 10.9% urine samples were positive for AFB by smear, 6.3 % by culture and 7.2 % on guinea pig inoculation. The culture yield was best in morning samples. Contamination was seen more often in 24 hours’ urine samples. Frequent cultures of urine from the same patient are advisable.

Introduction

Attempts to isolate Mycobacterium tuberculosis from the urine of patients with known genitourinary tuberculosis are frequently unsuccessful, possibly due to bacilli being excreted intermittently and in small numbers (Colby, 1961). That is why it is generally recommended that a 24 hours’ urine specimen should be used for isolation of Mycobacterium tuberculosis. However, a 24 hours’ collection in an ambulatory patient without refrigeration facilities may lead to lot of contamination and also necessitates an additional day for sedimentation. Besides, all the sediment is not processed for culture of Mycobacterium tuberculosis and if the part of the sediment that is cultured does not contain any bacilli, the purpose of 24 hours* collection is defeated. The present study was, therefore, undertaken to assess the comparative yield of Mycobacterium tuberculosis from 24 hours’ and morning urine samples. The study may also demonstrate the extent of kidney involvement in cases of pulmonary tuberculosis. Material and Methods

A total of 110 clinically, bacteriologically and radiologically proved cases of pulmonary tuberculosis were selected for the present study. Besides, 100 healthy individuals were also included to study the yield of Myco. tuberculosis in their 24 hours’, as well as morning urine samples after seeding them in different concentrations by a standard strain of Myco. tuberculosis Var. hominis (H-37 RV) obtained from Tuberculosis Research Centre, Madras. From 100 healthy individuals, morning and 24 hours’ urine samples were collected. Each sample was divided into two portions; one was autoclaved and the other remained unautoclaved. Urine sample was then artifically seeded with Myco. tuberculosis Var. hominis (H-37RV) in various dilutions (Table 1).

Table I Seeding dilutions of tubercle bacilli

All the urine samples were subjected to culture on L.J. media by Petroff’s concentration technique (Cruickshank, 1975). Simultaneously, urine samples were also inoculated into Guinea pigs (GP) sub-cutaneously. Sodium hydroxide/trisodium phosphate were used for concentration/homogenisation. A detailed history of antitubercular treatment taken by each patient was also obtained before culture/guinea pig inoculation. Each urine sediment was microscopically examined for the presence of pus cells, other sediments and for acid fast bacilli. Observations

A. Study on Healthy Individuals : In a study on 100 healthy individuals, it was found that yield of Mycobacteria was 85.7 % in morning autoclaved urine, 17.8% in 24 hours autoclaved urine, 41.7% in morning unauto-claved urine and 7.3 % in 24 hours’ unautoclaved urine. It was further observed that even the heavily seeded specimens of 24 hours’ urine had fewer positive cultures as compared to morning samples (Table 2). The urine samples collected on three consecutive days from the same individual did not show any significant difference in the yield of Myco. tuberculosis from autoclaved morning and 24 hours’ samples. However, percentage positivity with morning unautoclaved urine was

*Departments of Pathology and Bacteriology, Social & Preventive Medicine and Tuberculosis, K.G’s Medical College, Lucknow.

Ind. J. Tub., Vol. XXVIIl, No. 1

19

TUBERCULAR BACILLURIA—A CLINICO-BACTERIOLOGICAL STUDY Table II

Table III

Effect of reagents on culture yield (percentage) Culture yield Reagents

Autoclaved Unautoclaved Contamina tion M 24hrs M 24hrs M 24hrs

Sod. hydroxide 85.7 17.8 41.7 Tri-sod-phosphate ..

56.0

7.0 24.0

3.0

7.3

6.3

14.9

0.7 10.6

M = Morning sample

samples were positive by smear and 6.3 percent by culture. The positivity rate was higher in untreated patients than in treated ones. The yield was higher in untreated patients whose urinary deposits were washed with normal saline before smear or culture examination (Table 4). However, the difference was not statistically significant (p>0.05).

Average Positivity

85.7 17.8 17.8 14-3 41.7

7.3

6.1 57.1

M = Morning sample

Table IV Urinary smear and culture findings

quite variable, being 36.8 percent, 9.9. percent and 6.6 percent with three, two and one urine sample collections on different days. Similar findings were also obtained with 24 hours’ unautoclaved urine. The effect of sodium hydroxide and trisod. phosphate used during concentration process of urine samples was quite different as far as yield of Mycobacteria was concerned. The yield was better with morning as well as 24 hours’ autoclaved and unautoclaved samples when sodium hydroxide was used, as compared to the use of trisod, phosphate. However, the rate of contamination after concentration/homogenisation with sodium hydroxide was higher with morning and 24 hours’ urine samples (6.3 percent and 14.9 per cent respectively) in contrast to trisod. phosphate (Table 3). B. Study on Patients

Urine samples of 110 patients of pulmonary tuberculosis belonging to different age groups (7-65 years) and of both sexes (majority, 63.4 per cent, being males) were examined for AFB by smear and culture. In all, 10.9 per cent

*ATT = Anti-Tubercular Treatment

Among 110 patients of pulmonary tuberculosis, 42 were pyurics and 68 non-pyurics. Analysis of culture positive cases in relation to pyuria revealed that out of 7 culture positives, 5 were pyurics and 2 non-pyurics. Ind. J. Tub., Vol. XXVIII, No. 1

20

S . K . AGARWAL , V . K . SRIVASTAVA AND R . PRASAD

On correlation of the findings obtained after guinea pig inoculation and after culture, it was observed that 7.2% patients were positive by guinea pig inoculation and 6.3% by culture. However, a total of 10.9 percent patients were positive by either culture or guinea pig inoculation (Table 5). Table V

Results of culture positively and guinea pig inoculation (n = 110)

Discussion : Tubercular bacilluria is known to be associated with pulmonary as well as extra- pulmonary tuberculosis (Chadha and Sahi, 1971; Bentz et al, 1975) Asymptomatic renal tuberculosis is probably more common than has formerly been assumed (Kenney, 1960). However, some of the investigators believe that tubercular bacilluria occurs even in absence of renal lesions and was not necessarily proof of genitourinary tuberculosis (Medlar and Ordway, 1942). It has been generally accepted that 24 hours’ urine specimens should be used for isolation of mycobacterium tuberculosis because of the fact that the bacilli are few in small samples and appear intermittently. However, some authors (Kenney, 1960) have reported better yield with morning samples as compared to 24 hours’ samples because in ambulatory patients without facilities for refrigeration, there are more chances of contamination, and secondly, 24 hours’ specimens necessitate an additional day for sedimentation. Often, not all the sediment of 24 hours’ sample but only a part of it is inoculated for culture and, therefore, the purpose of 24 hours’ collection is defeated. The frequency of urine cultures positive for Mycobacterium tuberculosis among pulmonary tuberculosis patients has been reported to vary from 3.8 to 10 per cent (Hobbs, 1923, Chadha and Sahi, 1971; Bentz et al, 1975). The present Ind. J. Tub., Vol. XXVIH, No. 1

study was carried out to evaluate the various problems confronted during bacteriological diagnosis of genito-urinary tuberculosis and to determine the extent of secondary involvement of the kidney in patients of pulmonary tuberculosis. The study has shown in that the urine of bacteriologicaly confirmed patients of pulmonary tuberculosis was positive for AFB by direct smear in 10.9 per cent and by culture in 6.2 per cent. Chadha and Sahi (1971) have shown that the urine of 9.1 percent pulmonary tuberculosis patients was AFB positive by smear examination. However, Band (1943) and Bentz et al (1975) have reported higher AFB positivity in urine cultures (21.3 percent and 21 percent respectively). Kenney (1960) observed that introduction of anti-tubercular drugs has made the demonstration of tubercular bacilluria difficult. This could be either due to drugs causing healing of renal foci or the presence of drugs in urine inhibiting the growth of mycobacteria in the culture. In the present study, though there was a higher culture yield in those patients where the drugs had been stopped for a week prior to the test and centrifuged deposits of urine were washed with normal saline, but the difference was not statistically significant (P>0.05). AFB positive culture rate was found to be higher in pyurics as compared to non pyurics. Similar findinss have also been reported by Hill and Gow, 1966. As regards the comparative value of culture and G.P. inoculation, the present study has shown a slightly higher positivity rate with G.P. inoculation (7.2 percent) as compared to culture (6.3 percent). This difference, however, is not statistically significant and full reliance can not be placed on any one of the two techniques. Therefore, both procedures may be adopted simultaneously in the same patient for isolation of tubercle bacilli in urine. This observation is also supported by Hill and Gow (1966). The present study has also highlighted the various problems arising in urine cultures for AFB. An experimental study done on autoclaved and unautoclaved morning as well as 24 hours’ urine samples collected from 100 healthy individuals after artificial seeding with different concentrations of Mycobacterium tuberculosis var. hominis (H 37 RV), has clearly shown that morning samples give better yield of Mycobacteria both in autoclaved and unautoclaved specimens. Even the heavily seeded 24 hours specimens yielded fewer positive cultures as compared to morning samples (Table 2). Sodium hydroxide, a reagent used during concentration/homogenisation of urine for culture,

TUBERCULAR BACILLURIA

A CLlNlCO-BACTERfOLOGICAL STUDY

gives better yield of mycobacteria as compared to trisodium phosphate. However, contamination rate is higher with sodium hydroxide. This may be due to the fact that treatment with 2% sodium hydroxide for 45 minutes may not be sufficient to kill all the contaminants present in urine samples. Further, the treatment of urine samples with sodium hydroxide also reduces the viability of tubercle bacilli. The smaller yield with tri-sodium phosphate is because of the fact that it is a strong bactericidal reagent. Similar findings have also been reported by other workers (Kenncy, 1960). The yield of Mycobacteria was more when three urine samples from the same patient on three consecutive days were subjected to culture. This may be explained on the basis of intermittent tubercular bacilluria and bacilli being present in very low concentration in the urine. Repeated testing on different days, therefore, is likely to give better yield of Mycobacteria. These findings are in conformity with those of Kenney (1960). Hill and Gow (1966) and Chadha and Sahi, (1971).

21

REFERENCES 1. Band, D. Postgrad. Med. Jour., 1943, 19, 266, 2. Bentz, R.R., Dimecheff, D.G., Nemiroff, M.J.,Thang, A. and Weg, J.G. Am. Rev. Resp. Dis., 1975, 111, 647. 3. Chadha, S.K. and Sahi, R.P.; Intl. J. Tub.; 1971, 18, 54. 4. Colby, F.H.; Essential Urology, 4th Ed.; 1961; 552. 5. Cruickshank, R.; Text book of Medical Microbiology, Churchill Livingstone, Edinburgh, London & New York, Ed. XII, Vol. 2.; 1975. 6. Hill, C.A. and Gow, J.G. Brit. J. Urol.; 1966, 38, 163. 7. Hobbs, F.B.; Tubercle; 1923, 57, 105. 8. Kenncy, M. Am. Rev. Res. Dis,; 1960, 82, 564. 9. Medlar, E.M. and Ordway, W.H. Jour. Am. Med. Ass.; 1942, 119, 937.

Ind. J. Tub., Vol. XXVIII, No. 1

CASE REPORT TUBERCULOSIS OF THE TONGUE N.K. SONI ,* P. CHATTERJI ** and S.K. NAHATA *** Summary : A series of ten patients of tuberculosis of the tongue is presented. It accounts for 0.8 % of the total tongue diseases. Etiopathogenesis, symptomatology and treatment aspect of the condition are discussed in the light of available literature. The need for a high index of suspicion in diseases of the tongue is emphasized.

Tuberculosis of the tongue is not very common. Komet et al (1965) observed this in 1 % of the patients with pulmonary tuberculosis. In a review of 843 patients with tuberculosis, 16 were found to have upper respiratory tract tuberculosis and one of these had involvement of the tongue (Rohwedder, 1974). In approximately 498 patients with pulmonary tuberculosis admitted since 1969, in the V.A. Hospital, Atlanta, only two (0.2%) had oral tuberculosis; one had pharyngeal and another had tongue tuberculosis (Weaver, 1976). Solitary case reports have been reported by Engleman and Putney (1972), Gupta et al (1975) and Weaver, (1976). Material and Method The study consisted of ten patients of tuberculosis of the tongue seen in a period of 6 years from May, 1973 to May, 1979. The case history of each patient was thoroughly assessed to detect the clinical presentation, course and behaviour of the lesion. An attempt was also made to correlate the tongue lesion with pulmonary pathology. Response of the local pathology to the various antitubercular drugs was evaluated,

tongae tuberculosis belonged to the age group ranging from -20 to 40 years. The youngest patient was a male of 13 years and the oldest one was 69 years old. Males outnumbered females and male to female ratio was 4 : 1. Most of the patients were socio-economically poor and belonged to the labour class. The commonest lingual symptom was pain on swallowing (80%) which ranged from slight discomfort to severe pain causing fear of food intake. Such patients had mainly multiple small superficial ulcerations and diffuse ‘glossitis’ type of lesion. Patients also compalined of excessive salivation, development of ulcers and swelling (Table 1). Two patients had hoarseness of voice and laryngeal examination in these revealed lesions characteristic of tuberculous disease. Pulmonary symptoms were present in only 70% of the patients which were in the form of cough with or without expectoration, haemoptysis, fever, dysponoea etc. Table I Symptomatology in 10 patients of tuberculosis of the tongue

Observation

Ten (0.8 %) cases of tubercular lesion of the tongue were found out of 1,250 cases of total diseases of the tongue by the E.N.T. Unit. Of these 10 patients, 5 were diagnosed during a survey carried out to detect upper respiratory tract tuberculosis out of 600 patients of pulmonary tuberculosis in Tuberculosis and Chest Diseases’ Unit of the Hospital. Of the remaining 5 patients, 3 patients primarily attended the E.N.T. O.P.D. with complaints referrable to the tongue and 2 patients were referred to us for associated tongue lesions with established diagnosis of pulmonary tuberculosis. A majority of the patients (7 patients) with

Tuberculosis affected the various parts of the tongue and each site of the tongue was found to have different type of lesion as shown in Table It.

* Lecturer **Professor & Head and Medical Superintendent, ***Senior Registrar Sardar Patel Medical College & Associated Group of Hospitals, Bikaner (Rajasthati)

Ind. J. Tub., Vol. XXVIII, No. 1

TUBERCULOSIS OF THE TONGUE

23

Table III Character of lung lessions in 10 patients of tuberculosis of the tongue S.No

Character of lung lesion

No. of patient

1.

Infiltration

2

2.

Cavitation

4

3,

Pneumonic

1

4.

Miliary

1

5.

Old healed pathology

1

6.

No pathology

1

Total

10

type. In the remaining one patient, no evidence of tuberculosis elsewhere in the body could be detected. Five patients seen in the Tuberculosis & Chest Hospital showed a characteristic clinical picture of tongue tuberculosis and sputum was positive for A.F.B. No biopsy was done in these cases. Biopsy was done in 3 out of remaining five patients, who primarily attended the E.N.T. unit of this Hospital, because they had clinical picture of carcinomatous lesion of the tongue and histological examination revealed a characteristic picture of tuberculosis. Two cases had associated laryngeal lession; biopsy was therefore taken from the larynx, not from the tongue. Regarding the sputum bacteriology, seven patients (70%) out of 10, showed tubercle bacilli on direct smear examination. Lingual smear for A.F.B. was also done in all patients and was found positive in six, but one patient who was abacillary on routine sputum smear examination had tubercle bacilli in the lingual smear. This was subsequently confirmed by histological examination. Nine patients had associated pulmonary pathology on radiological examination of chest (Table III). Out of these 9 patients, 7 had bilateral pulmonary tuberculosis. The character of the chest lesions also varied. The commonest lesion was cavitary; the others were massive infiltrative, pneumonic or broncho-penumonic. Jn one patient, the disease was of the miliary

All patients were treated with various antitubercular regimens and showed good response, both locally as well as for the lung lesions. Discussion

There has been a reduction in oral and tongue tuberculosis in recent years (Table IV), but their unusual presentation has become relatively more common and this can lead to a delay in its corect diagnosis. Most of the cases of lingual tuberculosis are due to the highly infectious sputum from cavitary disease in the lung, although lymphatic or haematogenous involvement of the tongue is also possible. Tongue lesions have been desInd. J. Tub., Vol. XXVIII, No. 1

24

N.K. SONI, P. CHATTERJI AND S.K. NAHATA

Table IV Incidence of lingual tuberculosis according to different reports

Name of author

Year

Percentage

Morrow and Miller

(1924)

1.0

Myerson

(1944)

0.3

Titche

(1945)

0.3

Cawson

(1961)

0.2

Rohwedder

(1974)

0.1

Weaver

(1976)

0.1

Figure 1 : Photograph showing ulccrutivc form of tuberculous glossitis

cribed in miliary tuberculosis (Wilson and Stern, 1961). Involvement of the base of the tongue may be the result of direct spread from the epiglottis or larynx and was seen in one patient. ‘Primary lesions’ without any detectable evidence of tuberculosis in any other part of the body have been described by Kakar and Sood (3971). One of the ten patients in this series was supposed to have such lesion. Most of the patients reported in the literature are secondary to pulmonary tuberculosis, and a majority of them (80%) have been bacillary i.e. having bacilli in their sputum (Katz, 1941) thus favouring the direct implantation (or sputogenic) theory. On the contrary, some patients did not have bacilli in their sputum, but direct smears taken from the tongue lesion or histological examination, confirmed the tuberculosis pathology. This point is in agreement with the other two pathways of infection. Although there are many patients with pulmonary tuberculosis, lingual tuberculosis is not frequently met with inspite of the fact that the tongue is so frequently exposed to tubercle bacilli (sometimes in very heavy concentrations) from the sputum of patients with pulmonary tuberculosis. This local resistance of the tongue to tubercular infection is rather difficult to explain. However, the local pH of the oral cavity, regular cleaning of the tongue by saliva (which prevents any settling of tubercle bacilli on the tongue), the resistance of striated muscle in the tongue to tubercle bacilli, and a relative paucity of lymphoid tissue in the anterior part of the tongue (for which tubercle bacilli have a great affinity) could perhaps be some of the factors responsible for the rare occurrence of tubercular lesions in the tongue. Ind. J. Tub., Vol. XXVIII, No. 1

Figure 2 : Photograph showing tuberculous glossitis

No characteristic symptoms are ascribable to tuberculous disease of the tongue. These are common to many other diseases of the tongue. A tuberculous lesion may occur as an ulcer (Fig 1), a granuloma, fissure or glossitis (Fig.2). The diagnostic points for ulcemlive form are superficial nature of the ulcers, the presence of multiple foci and the pin-head yellowish spots

TUBERCULOSIS OF THE TONGUE

(Bryant, 1939). The ulcers are usually more irregular than those of carcinoma. Two of our patients showed clinical picture of malignant ulcer but on histological examination, they proved to be tuberculous. In addition, the tuberculous lesion should be differentiated from other chronic infective granulomatous conditions, such as syphilis, Vincent’s angina, lupus, Herpes etc. “Syphilis bites, tuberculosis nibbles”. Lupus lesions show superficial ulceration associated with healing and cicatrization. Prognosis of tuberculosis of the tongue is usually favourable with recent anti-tubercular drugs. Surgery is not required. Though tuberculosis of the tongue is an uncommon disease but the present ten cases reveal that the possibility of tuberculosis must still be born in the mind. REFERENCES

1. Bryant, J.C. : Oral Tuberculosis. Amer. Rev. Tuberc. 1939,39,738. 2. Cawson, R. : Tuberculosis of the Mouth and Throat. Brit. J. Dis, Chest; 1960, 54, 40. 3. Engelman, W.R.; Putney, F.J. : Tuberculosis of the tongue. Trans. Amer. Acad. Ophthal. Otolaryngeal; 1972, 76, 1385.

25

4. Gupta, H.L.; Chandna, R.S. and Patel, C. : Tuber culosis of the tongue. Ind. Jour. Tub.; 1975, 22, 163. 5. Kakar, P.K. and Sood, V.P. : Primary lingual tuberculosis. J. Laryngol. Otol; 1971, 85, 89. 6. Katz, B.C. : Tuberculosis of tongue. Quart. Bull. Sea View Hasp.; 1941. 6, 239. 7. Komet, H.; Scheffer, R.F. and McHoney, P.L. Bilateral tuberculous granuloma of the tongue. Arch. Otolaryngeal.; 1965, 2, 649. 8. Morrow, H, and Miller, H.E. : Tuberculosis of the tongue. J. Amer, Med. Ass.; 1924, 83, 1483.

9. Myerson, M. : Tuberculosis of the Ear, Nose & Throat. C.C. Thomas, Springfield; 1944. 10. Rohwedder, 3.3. : Upper Respiratory Tract Tuber culosis. Ann. Int. Medicine; 1974, 80, 708. 11. Titche, L. : Tuberculosis of the tongue. Amer. Rev. Tuberc.; 1945, 52, 342. 12. Weaver, R.A. : Tuberculosis of the tongue. J. Amer. Med. Asso.; 1976, 235, 2418.

13. Wilson, G.E. and Stern, W.K. : Tuberculosis of mouth and pharynx. Otolaryngology, Edited by Coates and Scheck, 4th Edition W.F. Prior Company, Hagerstown, Maryland; 1961.

Ind. J. Tub., Vol. XXVIII, No. 1

A STUDY OF DRUG DEFAULT IN PATIENTS ATTENDING TUBERCULOSIS CLINICS IN A RURAL AREA* V.K. SRIVASTAVA, R. CHANDRA, P.C. JAIN and J.K. BHATNAGAR Summary : In a study of 193 patients registered during July 76 to June 77 at three different TB. clinics of Rural Health Training Centre, Sarojini Nagar, 41(21.2%) were lost during the course of treatment. The defaulter rate was similar in the patients of self administered daily regimen of INH+ THZ, and biweekly (INH -f- SM) supervised regimen. An increase in the defaulter rate was observed with increase in the period of therapy. Family and occupational problems etc, constituted the main reasons of default. Problems attributable to the drugs and disease were responsible for 9.4 and 11.5% defaults respectively. Introduction

The problem of drug default has been commonly observed wherever therapy has to be continued for a long period. In case of tuberculosis, it is of great importance, since such patients are not only at a risk of developing drug resistant organisms (Rao, 1972) but could possibly be dangerous to others who might get infected with these organisms. The situation could only be dealt with if the extent of the problem in a particular area and its causes are known. The present investigation was carried out to assess the extent as well as the causes of drug default in-patients of pulmonary tuberculosis in the area of-Sarojini Nagar, a rural field practice area for interns and postgraduates of the Department of Social and Preventive Medicine, K.G.’s Medical College, Lucknow. Material and Methods The Tuberculosis Control Programme is functioning in Sarojini Nagar through the Primary Health Centre and Experimental Teaching Health Centres, Mati and Banthra of the Rural Health Training Centre, Sarojini Nagar, under the Upgraded Department of Social and Preventive Medicine, K.G.’s Medical College, Lucknow. All these centres are provided with microscopes. The Primary Health Centre, Sarojini Nagar is also provided with an X-ray plant and screening facilities. The drugs available for distribution at these centres are isoniazid (INH), thiacetazone (THZ) and streptomycin (SM). Two regimens are followed (i) Daily Regimen of isoniazid and thiacetazone for patients who cannot attend the clinic regularly and frequently, (ii) Bi-weekly Intermittent Supervised Regimen of isoniazid and streptomycin, for those patients who live

in proximity to the clinic and can attend it regularly twice a week. All patients at the time of registration are educated about the nature and course of the disease. The role of regular treatment and the hazards of discontinuity are also impressed on them. This motivation is repeated at subsequent visits of these patients. A patient was considered as ‘defaulter’ if he failed to collect the supply within 3 days of the due date. Defaulter action was taken three days after the due date. Action included visit to the patient’s home by an intern/paramedical worker. A post-card was sent to those patients who could not be visited. Another post-card was sent one week after the due date, if there was no response to the first post-card. If the patient failed to report within 2 months of the due date, the patient was marked as ‘lost’. A total of 193 patients registering between July 1976 and June 1977 were included in the present study. Observations Of 193 patients of pulmonary tuberculosis registered during the period July 76 to June 77, 172 (89.1%) were on a daily regimen of INH + THZ and 21 (10.9%) on bi-weekly supervised regimen of INH -f SM. As may be observed from Table 1, a total of 172 patients had therapy for at least 3 months, of which 35 joined during the last 3 months’ period and 52 after six months of the start of study. A total of 37 out of 172 patients on daily regimen were lost during their period of therapy. Of these 37, 9 losses were in the first 3 months? 13 in the next 3 months and 15 losses occurred during the last 6 months of the therapy.

*Presented at U.P. State Conference on Tuberculosis and Chest Diseases, Lucknow, November, 1977. (From the Upgraded Department of Social and Preventive Medicine, K, G’s Medical College, Lucknow).

Ind. J. Tub., Vol. XXVIII, No. 1

DURG DEFAULT IN TUBERCULOSIS PATIENTS IN RURAL CLINICS Table 1

27

Table 3 Frenquency of default

Patients on two regimens according to period of registration

Similarly, of 21 patients who were on a biweekly supervised regimen, 4 (19.0%) were lost, while 17 (81.0%) continued their treatment. In this group also, the percentage of defaulters increased with the increase in the period of therapy (Table 2). The differences between the two groups are, however, not significant in respect of default rate. Table 2 Defaulters on both regimen

Table 4. At times, patients gave multiple reasons, but one important cause was listed. Reasons attributable directly to the patients were 79.0% Occupation and family problems together accounted for 41.5% of the total defaults. The family problems mainly related to births, deaths, marriages, sickness etc. The occupational problems were mainly agricultural such as irrigation, harvesting etc. About 9.0% of the total defaults were due to relief in the symptoms and 5.8% due to toxicity of drugs. Discussion

A total of 193 patients of pulmonary tuberculosis were registered during July 1976 and June 1977 at three health centres of Rural Health Training Centre, Sarojini Nagar. The patients on a daily regimen of isoniazid and thiacetazone were 372, and on bi-weekly supervised regimen of isoniazid and streptomycin, twenty one. A total of 37 (21.5%) patients on daily regimen1 were lost during the course of treatment. The percentage of defaulters was lower (33.1 %) in the early period of therapy (first 3 months) and increased with the increase in the duration of therapy reaching upto 67.1 %. Khanna et al (1977) in their study at Lucknow, observed a slightly higher rate (75.9%) of defaulters in patients on INH-+-THZ regimen attending an urban clinic.

The number of defaults as shown in Table 3, were not more than two, but as the period of therapy extended, 3 or 4 defaults also became evident.

The defaulter rate for the patients on bi-weekly regimen and those on daily regimen were not significantly different. The number of defaults increased with the increase in the duration of Ind. J. Tub., Vol. XXVIII, No. 1

therapy. Majority of the patients defaulted once or twice and only a small number defaulted 4 or 5 times. Similar observations have also been made by Khanna et al (1977). Family and agricultural problems accounted for 41.5% of the total reasons for defaults. The family problems have also been emphasised by Patliak (1965). Forgetfulness was noted in 14.4 % of instances in the present study. In the study of Khanna et al (1977) carelessness and forgetfulness were reported to be the commonest cause and family problems for only 5.0% of the total defaults. Singh et al (1976) also reported similar observations. The problem of transport, long distances to clinic, and unsuitable clinic timings accounted for more than 20.0% of the defaults in the present study and also in the studies by Pathak (1965) and Khanna et al (1977). Relief of symptoms was responsible for 9.0% of total defaults and toxic effects of drug accounted for 5.8% of defaults. Khanna et al (1977) also reported nearly similar percentage attri-

Ind. J. Tub., Vol. XXVIII, No. 1

butable to toxicity of drugs. The toxic manifestations ranged from the feeling of heat to severe skin rashes in some cases. Similar drug reactions have also been reported by Gothi et al (1966) and Khanna et al (1977). REFERENCES 1. Gothi, G.D., O’Rourke, J.O. and Baily, G.V.J. (1966). Ind. J. Tub. 14, 41. 2. Khanna, B.K., Srivastava, A.K. and Ali, M. (1977) Ind. J. Tub. 24, 121. 3. Pathak, S.H. (1965). Proceedings Ind. Tub. Work Confer, p. 215. 4. Rao, K.N. (19721. Drug Resistance in Text Book on Tuberculosis’ p. 109, The Kothari Book Depot, Bombay. 5. Singh, G., Banerjee, S.C. and Mathur, S.K. (1976). Ind. J. Tub. 33, 98.

TUBERCULOSIS OF APPENDIX—A CASE REPORT

S.C. SASTRY, V.N. SEETHAPATHI RAO, D. MUKUNDA REDDY, G. LAKSHMAN PRASAD, P. SARADA, G. SUVARNA KUMARI, C.C. MOHAN REDDY, Summary : Two cases of tuberculosis of appendix, one presenting as acute appendicitis and the other as chronic pain in abdomen ultimately ending in subacute intestinal obstruction are presented. Incidence, pathogenesis and various clinical presentations are discussed briefly.

Tuberculosis of Appendix alone (Shah et al, 1967 & Patkin et al, 1964) or its involvement secondary to tuberculosis of ileo-caecal region is rare (Shah& Julundhavala, 1967). The subjects affected may occasionally present with symptoms and signs of acute abdomen. In the present report are included two cases wherein appendix was affected with tuberculosis. One case presented as acute appendicitis with tubercular disease confined only to the appendix and the other as acute intestinal obstruction due to inflamed appendix associated with tuberculosis of the ileum.

friable. There were adhesions across the terminal ileum. Ileum and caecum were normal. Adhesions were released and appendicectomy was done. The abdomen was closed after leaving a rubber drain, which was removed 72 hours later. Patient had mild wound infection with staphylococci and was discharged 20 days after admission. Pathologic findings

Appendix was 8 x 2.7 x 1.2 cm. Serosal aspect was covered with fibrin plaques. The wall of appendix was thickened and lumen contained greyish white necrotic material. Histopathological examination revealed well formed tuberCase Reports clous granulomas in mucosa, submucosa and serosa with epitheloid cells, central caseation, Case -I: and invasion with large number of Langhan’s A 22-year-old man was admitted with colicky giant cells, lymphocytes, plasma cells and abdominal pain and vomiting of 5days’ duration. mononuclear cells, an undoubted picture of Pain started centrally and subsequently localized active tuberculosis. (Figure 1). to right iliac fossa. He was moderately built, had a pulse rate of 104/mt, blood pressure 100/70 mm Hg and a temperature 101.6°F. A tender soft lump of about 6 x 4cm size was felt in the right iliac fossa. Bowel sounds were normal. Rectal examination revealed tenderness in its right lateral wall. Cardiovascular and respiratory systems were normal. A clinical diagnosis of acute appendicular abscess was made. Haemoglobin was 12 gms/100 ml. Total leukocyte count was 14,000/cu mm. Plain X-ray abdomen and chest did not show any evidence of tuberculosis. The patient was managed conservatively and was discharged six days later and was advised interval appendicectomy. He was readmitted about a month later. He had no problems except for occasional mild and vague abdominal pain. There was no mass felt in the right iliac fossa. Haemoglobin was 11 gms%. Total leukocyte count was 8,500/cu mm and a differential count showed 56 polys, 40 lymphocytes and 4 eosinophils. E.S.R. was 15mm/lst hour and blood urea was 18 mg%. Laparotomy was done through a right lower paramedian incision. The appendix was found to be grossly thickened and inflamed and

Figure 1 Photomicrograph of the Vemiform Appendix showing Typical Tubercles with Epitheloid Cells, Langhan’s Giant Cells and Areas of Caseation (Case 1).

Case - II :

A 60 years old Hindu male was admitted for investigation of a vague abdominal pain for 11 months and distension for 2 days. He was ill-nourished, moderately dehydrated with a pulse rate of 108/mt and blood pressure of

Department of Surgery Unit I & Pathology, Kurnool Medical College, Kurnool.

Ind. J. Tub., Vol. XXVIII, No. 1

30

S.C. SASTRY, V.N. SEETHAPATHI RAO AND D. MUKUNDA REDDY ET AL.

90/70 mm Hg. Abdomen was distended. Visible persistalsis of small bowel pattern was present. Rigidity and tenderness were present in right iliac fossa. Repiratory and cardiovascular systems were normal. A provisional diagnosis of subacute intestinal obstruction probably due to tuberculous strictures of small bowel was made. Hemoglobin was 12.5 gms% blood urea 70mg%, serum sodium 120 m Eq/1 and serum potassium 3 mEq/1. Urine was normal. X-ray abdomen revealed distended bowel loops and multiple fluid levels. After correcting dehydration and electrolyte imbalances, abdomen was explored through a right mid-paramedian incision. There was ascites, mesenteric lymphadenitis, adhesions between omentum, terminal ileum, appendix and mesenteric nodes. Appendix was long, grossly thickened, finflamed and studded with grayish white tubercles. In addition there were multiple tuberculous strictures in mid ileum. Terminal ileum and caecum were normal. Adhesions were released. Appendicectomy, mesenteric node biopsy and enterostomy by passing the strictured loops were done. Abdomen was closed after instillation of streptomycin powder. Postoperative period was uneventful. Antituberculous treatment was started in the immediate postoperative period. The patient was discharged 10 days later. Pathologic findings

Appendix 10 x 2.5 x 1 cms, congested, with fibrin plaques grayish white innumerable tubercles of each 1 mm size over serosa. (Figure 2). Lumen contained necrotic material. Histopapathology revealed a typical picture of tuberculosis both in appendix and mesenteric nodes. Discussion Inspite of the fact that intestinal tuberculosis is an important cause of morbidity and intestinal obstruction, tuberculosis of appendix with or without ileal or caecal involvement is rare. Appendix seems to be more frequently involved secondarily from ileo-caecal tuberculosis (V. Bhasin et al). But the Shah & Jalundhawala series of 20 specimens of appendix obtained from right hemicolectomies done for ileo-caecal tuberculosis, did not show any evidence of appendicular involvement.

Palmar (1957) reported that 0.3% of the appendices removed surgically were tuberculous. During the last 19 years, only 11 cases (0.6%) of all surgically removed appendices were found tuberculous in our department. Ind. J. Tub., Vol. XXVIII, No. 1

Figure 2 Photograph showing gross Appearance of appendix with pointers showing tubercles on serosa.

The rarity of tuberculosis of appendix perhaps may be due to the fact that the contact between appendicular mucosa and intestinal contents is minimal (Bhasin et al, 1977). Tubercular appendicitis as the only manifest tuberculous lesion may present in three clinical forms (Borrow & Friedman, 1956). It may occur as an acute disease and can be differentiated from pyogenic appendicitis only by microscopic appearances.. The first case in the present report belongs to this group. The second type of presentation is chronic disease clinically indistinguishable from ileocaecal tuberculosis. But at laparotomy, caecum and ileum are free from disease. This is more common than acute form. The third one is a latent type, discovered incidentally in which the organ is unchanged in gross appearance. In the second case tuberculous appendix was present as a chronic form associated with intestinal obstruction. REFERENCES 1. Borrow, M.L., Friedman, S.—T.B. Ainer. J. Surg. 91, 389-393, 1956.

Appendicitis.

2. Boyd—Text Book of Pathology (8th Edition) p. 831 Lea & Febiyer Philadelphia. 3. Bhasin, V., Chopra, P., B.M.L. Kapur—Acute tuber cular appendix. Int. Surg. 62CIO) 563-564—1977.

4. Palmar, E.D., Clinical Gastroenterology—p. 310, Cassell, London. 5. Shah, R.C., Jalundhawala, J.M.—Tuberculosis of Appendix. /. Indian Med. Assoc. 49, 138, 1967. 6. Patkin, M., Robinson, B.L.—Tuberculosis of Appen dix. Br. J. Clin. Pract. 18., 741. 1964.

A SHORT REVIEW THE TUBERCULOSIS ASSOCIATION OF INDIA 35th National Conference on Tuberculosis & Chest Diseases held at Bombay from 19th to 23rd November, 1980.

S.P. PAMRA* The 35th National Conference held at Bombay was very successful and created several landmarks. The Maharashtra State Anti-TB Association is the first State Association to host this Conference for the fourth time for which the Association and its very dynamic and dedicated band of workers were very rightly congratulated. The number of registrations for this Conference was about 650, the highest ever. The Conference was held in a 5star hotel, again for the first time. The arrangements for the scientific sessions and other ancillary activities were excellent and left nothing to be desired. The standard of scientific papers was appreciably higher than in the previous conferences. Most of the papers were presented by younger workers, who, obviously under the guidance of their seniors, had prepared the papers very well. The presentations were concise and invariably within the time limits. The discussions were meaningful, to the point and of a high standard. The social programme was also of a very high order and off the beaten track of the usual dance and music performances. The organisers arranged a special programme in the Nehru Planetarium and a Judo-Karate show in addition to a special sight seeing programme for the ladies. Inauguration

Air Chief Marshal (Retd.) O.P. Mehra, Governor of Maharashtra, was the Chief Guest at the inaugural session. In his address he mentioned about the colossal national loss due to tuberculosis, its association with poor living conditions, ignorance and uncivic habits. While referring to the inadequacy of the infra-structure in the control of disease, he emphasised the necessity for constant vigil and research with a view to bring about maximum utilization of our slender resources. He regretted that the achievement of Maharashtra in respect of TB seal sale was not commensurate with its status and exhorted the people of Maharashtra to contribute liberally to this campaign. After the invocation the delegates were welcomed by Dr. M.D. Deshmukh, the moving pirit of the Maharashtra State Anti-TB Asso-

ciation and the Organising Committee. Dr. G.A. Panse, Deputy Director of Health Services (T.B.), Government of Maharashtra, highlighted the tuberculosis control programme in Maharashtra State and mentioned that l/3rd of the 10 lakh patients in the State were receiving treatment at the Government institutions. Shri Homi J.H, Taleyarkhan, Chairman, Conference Committee, highlighted the main activities of the State Association and solicited more effective coordination, recognition and increased assistance from the official agencies. Dr. S.P. Pamra, Honorary Technical Adviser of the Tuberculosis Association of India, urged tuberculosis control to be a centrally sponsored scheme with 100% central subsidy. He also pleaded for a second national sample survey and another study to determine the protective effect of BCG in respect of manifestations of tuberculosis (which were not studied in the earlier Chingleput trial) in children in the vulnerable age group. Dr. B.N.M. Barua, Tuberculosis Adviser to the Government of India, said that the national tuberculosis programme would be implemented very soon in about 50 of the bigger districts which are at present without a District Tuberculosis Centre. Dr. Bahrain Hire, Health Minister of Maharashtra, who inaugurated the Conference, wanted health education to be disseminated amongst the poor people both in the urban and the rural areas with a view to check spread of the disease. He pointed out that a large number of multipurpose workers were being trained in Maharashtra to step up case-finding and supervise domiciliary treatment in all the 26 districts of the State. He announced that the Government was considering enhancement of the annual grant to the State Association. He also released a book written by Dr. M.D. Deshmukh and lighted the traditional lamp to signal the inauguration of the Conference. Dr. M.M. Singh, President of the 35th National Conference, in his Presidential Address referred to the fact that the national programme had yet to be implemented in about 80 districts in the country and hoped that this deficiency would be removed as expeditiously as possible.

*Hony. Technical Adviser, Tuberculosis Association of India

Ind. J. Tub., Vol. XXVIII, No. 1

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He wanted the production of anti-TB drugs to be stepped up to the licensed capacity of the manufacturers. He also referred to the shortage of miniature x-ray films and wanted the Government either to arrange manufacture of these films like conventional size films in the country itself or to allow regular imports sufficient to meet the country’s needs. He advocated reorientation of the admission and discharge policies to hospital beds with a view to maximum utilization of the existing beds and also the need for a fresh look at the protective effect of BCG. Dr. R.K. Menda, President of the Indian Medical Association, referred to the importance of preventive measures including BCG as well as the psycho-sociological factors in the development of disease. He made a strong plea for mounting a war on tuberculosis in which all medical workers including the general practitioners and the para-medical workers must join. The Governor presented the ‘Wander-TAI Oration’ award to Dr. S.P. Tripathy, ‘Chanchal Singh Memorial Award’ to Dr. V.K. Perumal, ‘Dr. B.K. Sikand Memorial Gold Medal’ to Dr. Gurdeep Singh Kohli and the cash prize for an essay by a final year medical student to Shri Viswanathan Rajaraman-. Shri S.B. Somani released the conference souvenir. Dr. V.S.J. Rao moved a vote of thanks and the inaugural session ended with the national anthem. Scientific Sessions Three foreign dignitaries attended the conference as special guests. Prof. P. Sensi delivered the guest lecture on “An updated Pharmacological Profile of Rifampicin” immediately after the inaugural session. The lecture which highlighted the present status of Rifampicin in the management of tuberculosis and leprosy was very educative and was highly appreciated. Prof. G. Daddi delivered the guest lecture on “Occupational Diseases of the Lungs”. He covered a very wide field in an interesting presentation. The third dignitary, Dr. Southgate of Dow Chemicals Regional Office in Hong Kong also participated in the conference. Dr. S.P. Tripathy in his Wander-TAI Oration covered the subject of ‘Relapses in Pulmonary Tuberculosis’. He traced the decline in relapse rates with progressive improvement in chemotherapy and virtual elimination of relapses with Rifampicin-containing short course regimens. He also presented evidence to show Ind. J. Tub., Vol. XXVIII, No. 1

that most of the relapses were caused by bacilli which were still sensitive to the drugs used in the previous treatment. In his paper selected for the Chanchal Singh Memorial Award, Dr. V.K. Perumal reported on the immunological studies, relation between delayed hypersensitivity and cellular immunity and antibody levels in tuberculosis. He also presented evidence to show that Rifampicin was not an immuno-suppressive drug. Two very important subjects, viz. “Tuberculosis Management as an integral part of Primary Health Care” and “involvement of General Practitioners in the National Tuberculosis Programme” were covered in a Symposium and Panel Discussion respectively. Dr. K.N. Rao who was to chair the session with Dr. B.N.M. Barua could not attend the conference and his place was taken by Dr. S.P. Pamra. Dr. Pamra referred to the Alma Ata declaration of “Health for all by the year 2000 A.D.” and the W.H.O. directive to the member nations to work out the blue-print for delivery of primary health care in respect of tuberculosis within the next two years. The five speakers who participated in the symposium highlighted the role of workers at various levels from the Directorate of Health Services right up to the primary health centre in the delivery of tuberculosis services. The necessity for utilizing the multi-purpose workers, the community health volunteers and the influential and enlightened members of the society at the periphery in stepping up case-finding, case-holding and immunization was effectively covered. The Panel Discussion on “Involvement of General Practitioners in Diagnosis, Case-detection, Treatment and Prevention of Tuberculosis” was moderated by Dr. R. Viswanathan and included two general practitioners from Maharashtra. The consensus of the discussion was that general practitioners should take their rightful place in diagnosis and treatment of pulmonary tuberculosis and it was the responsibility of the official agencies to provide adequate facilities to the general practitioners for sputum and x-ray examination of their patients free of cost. A plea was also made that when the general practitioners were willing, their clinics should function as sub-centres of the D.T.C. for purposes of diagnosis, free supply of drugs, etc., especially in the rural areas. In another session the “Role of Hospitals in the Present-Day Management of Pulmonary Tuberculosis” was discussed. It was brought out that contrary to the position in the western countries there is still a great need for hospital beds in tuberculosis and this need would persist

35TH NATIONAL CONFERENCE ON TB & CHEST DISEASES

for many years to come. The participants agreed that even though pressure .on beds is less now because of effectiveness of domicilliary treatment, admission and discharge of patients to the hospital should be so regulated that there is maximum utilization of the existing beds and that domiciliary treatment and hospital treatment should be fully co-ordinated. There was a general discussion on BCG Vaccination in a special session. Various speakers referred to the fact that the recent Chingleput trial did not study some manifestations of tuberculosis which occur in small children soon after primary infection and which were usually abaciliary but had serious prognosis. Another study to determine the protection of BCG against these manifestations was therefore necessary. The conference unanimously recommended that such a study should be taken up as expeditiously as possible and till the results of this study were available, BCG vaccination of children in the vulnerable age group should continue as at present. Two sessions were devoted to ‘Chemotherapy’. Four papers dealt with short-term chemotherapy of tuberculosis in adults and children. A number of papers were presented on toxicity and inter-action of anti-TB drugs. Five papers were presented on different aspects of ‘Bronchogenic Carcinoma. A number of papers on diverse subjects were presented in six sessions on assorted papers. Important amongst these were the ‘Studies on the Use of Levamisole’, ‘Prevalence 1 Survey in Kashmir Valley , ‘Aetiological Studies on Pleural Effusions1 ‘Bacteriological Studies on Culture Contamination’ and ‘Repeated Use of Microscope Slides’. Two papers were presented on ‘Surgical Aspects of Treatment’ and five on ‘Non-tuberculous Chest Conditions’ and ‘Extra-pulmonary Tuberculous Manifestations’. Summaries of the papers presented at the Conference will be published in the April, 1981 issue of the Indian Journal of Tuberculosis. Concluding Session Dr. M.M. Singh gave a brief resume of the proceedings of the conference. Drs. K.V. Krishnaswami. P.A. Deshmukh, K.C. Mathur and K.C. Mohanty were elected to represent the National Conference on the Central Committee of the Tuberculosis Association of India. Dr. K.V. Krishnaswami moved a vote of thanks on behalf of the delegates and Dr. M.D. Deshmukh rounded up the conference with a

33

vote of thanks to the delegates who had attended the conference in such a large number. All in all, the conference was highly successful, efficiently organised and produced rich scientific fare. Technical Committee Meeting The Technical Committee of the Tuberculosis Association of India met after the concluding session. Dr. M.M. Singh, President of the Conference, was requested to prepare a note on the recommendations arising out of his Presidential Address for discussion at the next meeting of the Technical Committee. The Committee suggested the following special subjects for (he 1981 conference :J. 2. 3. 4.

Acute respiratory infection in children Respiratory failure in children Immunology of TB Operational aspects of case-holding and case-finding 5. Geriatric TB 6. Socio-economic aspects of tuberculosis. The programme will, as usual, include papers on ‘Chemotherapy’ and other assorted aspects. The Technical Committee accepted the invitation of the Gujarat TB Association to hold the 36th National Conference in that State: preferably in Baroda, but left the Hnal selection of the venue to the State Association. The Technical Committee also endorsed the recommendation of the conference in respect of BCG vaccination. The proposal for study of intermittent short-term chemotherapy as a cooperative study from 3to 6 centres as proposed by the Research Committee was accepted. It was also decided that the State TB Associations may again be reminded about the study on problems of drug default and its retrieval and this cooperative study should also be started during the next year. The question of supply of newer drugs to the Government clinics for free distribution, the role of general practitioners and indiscriminate marketing of Rifampicin were referred to the Local Advisory Committee. After disposing of the routine agenda, the Technical Committee discussed in general the celebrations to be organised in connection with the Centenary of the Discovery of Tubercle Bacillus in 1982. Shri A.V. Modi and Dr. V.C Talwalkar highlighted the salient points of a Ind. J. Tub., Vol. XXVIII, No. 1

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programme that they wish to implement during the next year for stepping up all anti-tuberculosis activities. Shri Modi, Dr. Talwalkar and all the members of the Technical Committee were requested to send their proposals, in detail, to the Secretary-General, T.A.T- within the next 2/3 weeks so that the final programme could be chalked out in this connection at an early date. Shibir

The Organising Committee of the conference had arranged a case-finding-cum-immunization shibir at Chirner and Suneri near Bombay i n collaboration with the Chirner ‘Arogya

Kendra’ on the last day of the conference. A total of 6,019 BCG vaccinations were given and 291 symptomatics were examined, out of whom 23 were found to be suffering from active pulmonary tuberculosis, 10 being sputum positive. Fifty delegates accompanied the team from Bombay to Chirner, After seeing the work of the Shibir, they were taken round the village by Dr. Vasant Talwalkar and shown the various improvements brought about in the village and the commendable health care and development activities of the “Arogya Kendra” with the whole-hearted and active cooperation of the community itself.

NOTICE TO SUBSCRIBERS Those who have not yet renewed their annual subscription for the Indian Journal of Tuberculosis for the year 1981 may kindly do so immediately by remitting a sum of Rs. 40/- to the Secretary-General, Tuberculosis Association of India, 3, Red Cross Road, New Delhi-110001. (Subscribers may. kindly include Re. 1/- as Bank charges for outstation cheques.)

Ind. J. Tub., Vol. XXVIII, No. 1

BOOK REVIEW AN INTRODUCTION7 TO TUBERCULIN TESTING AND BCG VACCINATION by A.N. Shashidhara; published by Messrs IBH Prakashana, Gandhinagar, Bangalore560 009; 1980; Pages 119; Price Rs. 22.50.

EARLY DETECTION OF CHRONIC LUNG DISEASES. EURO Reports and Studies 24; WHO Regional Office for Europe; 1980

The book deals comprehensively with theory and practice of tuberculin test and BCG. It covers the scientific basis of the tuberculin test, types of tuberculins and techniques of testing and reading and interpretation of the tuberculin reaction. Similarly, properties and preservation of BCG, technique and rationale of vaccination have been fully described.

A working group of 20 experts was convened in Vienna in 1978 to advise WHO on the risk of developing chronic non-specific lung diseases (CNSLD), review and evaluate methods for prevention and control and to suggest areas needing further investigations and development. CNSLD is more common in men, especially in middle and old age. Pattern is not uniform in all countries but it is an important cause of death apart from considerable interference with the patients’ work and demands on the health services. A distinction is made between two syndromes viz. a hypersecretory syndrome i.e. chronic phlegm production which is reversible and carries a good prognosis and an obstructive syndrome which is irreversible and leads to chronic disability and death. Chronic cigarette smoking and air pollution, both in special occupations and general environment, are important aetiological factors in addition to respiratory disease in childhood and innate susceptibility to respiratory pathogens and irritants. Contribution of air pollution is probably not as large as that of smoking. If smoking is given ,up, phlegm may completely disppear in the hyper-secretory phase, but not so if obstructive phase has set in. Further research is indicated into the natural history of CNSLD, particularly the reasons for progression of disease in some and not in others, early detection, predisposing factors and the role of anti-biotics particularly in early stages and effectiveness or otherwise of broncholdilators. S.P.P.

The author has not only been involved in tuberculin testing and vaccination for nearly quarter of a century but is also responsible for training of personnel in these aspects at the National Tuberculosis Institute, Bangalore. Thus, theoretical aspects of training of personnel detailed in this volume may not be available in any other similar volume. The book will be extremely useful for all those who have to carry out tuberculin test and BCG Vaccination in routine practice. It is indispensable for those responsible for training of personnel and those engaged in research studies of any type comprising tuberculin testing. S.P.P.

Ind. J. Tub., Vol. XXVHI, No. 1

NEWS AND NOTES 36TH NATIONAL CONFERENCE

The 36th National Conference on Tuberculosis and Chest Diseases will be held in Gujarat in October/November 1981 under the joint auspices of the Tuberculosis Association of India and the Gujarat State Tuberculosis Association. The Technical Committee of the Tuberculosis Association of India has tentatively selected the following subjects for discussion at this Conference : 1. 2. 3. 4.

Acute Respiratory Infection in Children. Respiratory failure in children. Immunology in TB. Operational aspects of case-holding and Case-finding. 5. Geriatric T.B. 6. Socio-economic aspects of tuberculosis. These subjects will be in addition to Chemotherapy and papers on assorted aspects. Those who wish to present papers at the Conference may kindly send an abstract of their paper on the above mentioned subjects or on any other subject of their choice to the Secretary-General, Tuberculosis Association of India, 3, Red Cross Road, New Delhi-1, latest by the 3Ut March, 1981. ANTI-TB DAY

The Association has selected “TUBERCULOSIS IS PREVENTABLE: HELP FIGHT TB1’ as the theme for the ‘Anti-TB Day’ (23rd February) in 1981. It is proposed to organise an intensive health education programme during the week 17th to 23rd February, 1981, through the media of newspapers, radio, T.V., public lectures, film shows, etc. to educate the people about the various aspects of the TB Control Programme and especially to propagate the idea that tuberculosis is preventable and curable. All State Associations have also been requested to organise similar programmes and make a concerted effort to sell the maximum number of TB Seals during the Anti-TB Week. HEALTH VISITORS’ COURSE

The 1981-82 TB Health Visitors’ Course will commence in July, 1981. The course will be of nine months duration and will be held at the New Delhi TB Centre (including two weeks in a rural centre). The minimum qualification for admission to this course is Higher Secondary/ Pre-University with Science or Hygiene and Ind. J. Tub., Vol. XXVIII, No. 1

Physiology in Matriculation. Application forms for admission to this course can be had from the Secretary-General, Tuberculosis Association of India, 3, Red Cross Road, New Delhi-110 001. The last date for receipt of application is 30th April, 1981. CHANCHAL SINGH MEMORIAL AW4RD— 1981

The Tuberculosis Association of India will award a Cash Prize of Rs. 500/- to a TB Worker, below 45 years of age, for an original article not exceeding 30 double spaced foolscap typed pages, (approximately 6,000 words) excluding charts and diagrams on a subject relating to tuberculosis. Papers may be sent in quadruplicate to reach the Secretary-General, Tuberculosis Association of India, 3, Red Cross Road, New Delhi-110 00], before 16th August, 1981. STATE CONFERENCE

The third Uttar Pradesh State TB & Chest Diseases Workers Conference was held in Varanasi on the 21st and 22nd December, 1980 under the joint asupices of the Uttar Pradesh TB Association and the Varanasi District Association. The Conference was inaugurated by the Hon’ble the Health Minister of U.P. and it was presided over by Dr. M.M.S. Siddhu, M.P., Honorary Secretary of the State TB Association. Dr. S.P. Pamra, Honorary Technical Adviser to the TAI gave the Guest Lecture on ‘B.C.G.—Historical review and current status’. Over two hundred delegates attended the Conference. The Hon’ble Minister stressed the importance of preventive and promotive health measures in addition to medical care in the control of disease and exhorted the tuberculosis workers to give due attention to these aspects also. Dr. Siddhu in his presidential address made a plea for a second National Sample Survey and sociological and operational ressearch for proper planning and execution of programmes and policies. He also referred to the problems of sputum negative cases, contact surveillance and involvement of voluntary and social organisations in the fight against tuberculosis. A very distinctive feature of this State Conference was that almost all D.T.O’s of the State and a large number of para-medical workers attended it and some of the latter also presented papers on their activities.

37

NEWS AND NOTES

The scientific session was inaugurated by Dr. Nag Choudhury, Director of the Institute of Medical Sciences of Banaras Hindu University. In all, 31 papers were presented covering the National Tuberculosis Programme, B.C.G., short course chemotherapy, allergic disorders, chronic bronchitis, etc. The attendance throughout the scientific sessions was very good, the arrangements were excellent and the hospitality very lavish. REFRESHER COURSES The Krishna District TB Association in Andhra Pradesh organised a Refresher Course on TB at Machilipatnam on November 9, 1980. The scientific session organised during the occasion included papers on “Role of TB Associations in National TB Control Progrmme in Andhra Pradesh”, “Diagnosis of Pulmonary TB,” “Management of Pulmonary TB”, “Nontubercular Chest Diseases”, “Pitfalls in the diagnosis of Pulmonary TB” and “Role of Surgery of lung disease”, etc. More than 100 doctors attended the course. The Delhi Medical Association organised a Symposium on 14th and 15th November, 1980, for general practitioners. Dr. S.P. Pamra was the Moderator. All aspects of Tuberculosis were covered. The other speakers included Dr. H.K. Chuttani, Dr. H.B. Dingley, Dr. Satya Gupta, Dr. G.D. Gothi and Dr. M.M. Singh. The Gujarat State TB Association will be organising a Refresher Course in TB at Jamnagar sometime in January 1981. The TB Association of Agra, Uttar Pradesh, has been holding a one-day Refresher Course for the benefit of Rural Medical Practitioners once a month (on the last working day) at different block/PHC levels. It is also proposed to hold a six-day Refresher Course in TB & Chest Diseases from February 9 to 14, 1981, at the TB Demonstration and Training Centre, Agra, for the benefit of Medical Post-graduates. TB CAMP The Prakasam District TB Association in Andhra Pradesh conducted a TB Camp in Dornal Village under the guidance of the District Medical and Health Officer. 147 symptomatics were investigated for TB and 28 patients were diagnosed. 238 children were given BCG vaccination. The next Shibir will be conducted in Naguluppalapadu village of PHC Ammanabrolu.

The Kodagu District TB Association in Karnataka organised mass BCG vaccination and TB Detection Camps at Kutta, Murnad, Shanihalli, Virajpat and Sampje. In all 1,723 persons were BCG vaccinated and 304 patients were given medicines. INAUGURATION OF 31ST TB SEAL CAMPAIGN In Andhra Pradesh the Campaign was inaugurated on 3rd October, 1980, by Shri N. Nelakanta Sarma, General Manager, South Central Railway, Secunderabad. Dr. S. N, Mathur, DMS (Retd.), inaugurated the Health Check-up Camp for Cycle Rickshaw Drivers in the twin cities on the occasion. In Bihar the Campaign was inaugurated by the State Governor, Dr. A.R. Kidwai, ata function presided over by Shri Shamaela Nabi, the State Minister for Health and Family Welfare. Dr. S.P. Pamra, Technical Adviser, TAI, was the Chief Guest. Dr. Pathak, Director, Jagjiwan Sanatorium and Chairman of the Association also addressed the gathering. In Goa, Daman & Diu, Shri Shaikh Hassan Haroon, Health Minister, inaugurated the Campaign in the Janta Library Hall at Vasco (Goa) on 2nd October. The Rolling Shield for the highest, collection made during the previous Campiagn was awarded to the Care and After-Care Committees, Vasco and Merit Certificates to various organisations and individuals. In Gujarat, Dr. H.N. Patel, Director, Medical and Health Services, Gujarat, inaugurated the Campaign at the Medical Association building. The Campaign was inaugurated in Kashmir by Begum Sheikh Abdullah at the premises of the Association in Karan Nagar by making a personal donation of Rs. 400/- on the spot. Dr. Tahir Mirza, Secretary of the Association also addressed the gathering. In Kerala, the Campaign was inaugurated by Smt. Jothi Venkatachellum, Governor of Kerala, at the premises of the Kerala State Child Welfare Council. Shri Vakkom Puroshothaman, Minister for Health & Tourism, presided. The Seal Sale Trophies were awarded to the District Collectors of Trivandrum and Kozhikode. In Karnataka, the Campaign was inaugurated at Bangalore by the Governor, Shri Govind Narain at Raj Bhavan on 3rd October. The Governor also gave a broadcast talk over the AIR explaining the significance of the Campaign. In Maharashtra, Shri Ramrao Adik, Minister for Finance and Urban Development, Maharashtra, inaugurated the campaign at the Indian Merchants Chamber on the 9th October, 1980. Shri Homi J.H. Taleyarkhan, Senior Vice-president of the Association and Dr. M.D. Deshmukh, Honorary Secretary, addressed the gathering. In Madhya Pradesh, the GoverInd. J. Tub., Vol. XXVIII, No. 1

NEWS AND NOTES

nor inaugurated the Seal Campaign at Raj Bhavan and made a token purchase of Seals worth Rs. 100/-. In Indore, Shri Srinivas Tiwari, Minister for Health & Family Welfare, inaugurated the Campaign. An exhibition on Health was organised on the occasion and a special Bulletin of Kshyaya Pidit Sahayak Sangh, Indore, ‘Nirala Duniya’ was brought out. Dr. N.L. Bordia, the founder-member of the Sangh, also addressed the gathering. In Tamil Nadu, Dr. N.V.R. Nedunchezhiyan, Minister for Finance, inaugurated the Seals Campaign. Dr. H.V. Hande, Minister for Health,

Ind. J. Tub., Vol. XXVIII, No. 1

presided over the function and Shri H.M. Veerappan, Minister for Information and Religious Endowments, presented the awards for highest collections made by the Districts. The Association has instituted a Rolling Shield known as the “Dr. Rajah Sir Annamalai Chettiar Birth Centenary Trophy (1880-1980)” to be awarded to the District TB Association performing the most outstanding anti-TB work during the year. It may be recalled that the State Chief Minister, Shri M.G. Ramachandran, had given a special television-radio talk on the eve of the inauguration of the Campaign.

The Indian Journal of Tuberculosis ABSTRACTS Vol. XXVIII

January, 1981

The quantified increase of the Tuberculosis infection rate in a low prevalence country to be expected if the existing MMR programme were discontinued.

K. Styblo and I. Meijer—Bull. Inter. Un. Tub; 1980, 55,3.

Abst. No. 1

in the case of 33 deaths. Majority of the pneumonectomies viz. 108 were performed during the years 1950-52. The indication for pneumonectomy was cavitary tuberculosis in 72, empyema with broncho-pleural fistula in 24, destroyed lung in 55 and stenosis of main bronchus in 8. The remaining 9 pneumonectomies were for non-tuberculous causes. In 56 cases thoracoplasty had also been done in addition to pneumonectomy. The purpose of additional thoracoplasty was not to cope with the pleural space but in order to deal with the sequelae of earlier treatment carried out when resection was not possible or for post-pneumonectomy empyema/ bronchopleural fistula.

The yield of mass miniature radiography (MMR)in a low prevalence country, viz., etherlands has been worked out. In a control programme with MMR, the time lag between appearance of symptoms and diagnosis was 2.5 months for both smear positive and culture positive cases. Among cases detected through MMR, the lag period was 1.7 months. It was also worked out that on an average one unknown All 18 persons who were operated in the smear positive case infects 13 persons i.e. one age group 5 to 19 years survived whereas 11% per month. The culture positive case infects, on died in the age group 20 to 29. The risk of death was appreciably more when thoracoplasty was an average, about 0.2 person per month only. done in addition to pneumonectomy, especially In 1974, the annual infection rate in Nether- when the surgery was on the right side (8 deaths lands was 2.8 per 10,000. If the existing MMR out of 9). The death was related to tuberculosis programme had been discontinued on 1st or its sequelae in 18 cases (chronic nephritis January, 1974, the number of freshly infected 5, pneumonia 3, respiratory and cardiac insufpersons would have increased only by 46, ficiency 10). In 15 cases, death had no relationi.e. the infection rate would have increased ship to tuberculosis (accidents 3, inter-current disease 12). from 2.8 to 2.83 per 10,000 in 1974. S.P.P. Even in women with considerably limited pulmonary function, neither pregnancy nor The patient after total pneumonectomy delivery caused any serious problem. 33 women Laros, C.D., Selected paper; Volume 19; The had 3 postpneumonectomy children and the confinement was more or less normal. Apart Royal Netherlands Tuberculosis Association; from some extreme displacement of the abdomiThe Hague, 1979. nal organs or the remaining lung into thoracic 168 patients whose pneumonectomy had cage, there was considerable rotation of the been done in a surgical unit in Netherlands heart. The diffusion capacity of the lung was more than 20 years ago have been studied. This considerably reduced. Probably quantitative loss number does not include 23 patients who had of the lung tissue is a more important determidied within 5 years after penumonectomy (13 nant of life expectancy than the qualitative within one month and 10 between 8 months impairment. S.P.P. and 4 years after surgery). Out of the 168 patients, 135 were alive at the end of 20 years or more after penumonectomy and 33 had died Changing patterns of the causes of death of tuberculous patients between 5 and 20 years after surgery. 117 were women and 51 men. Majority of the persons M. Aoki et al, Bull Int. Un. Tub.; 1979, 54, were in the age group 20 to 39 years at the time 311. of surgery. The average period of follow up is Among a total population of 2 million in 22.0 years in 135 living patients and 15.2 years Ind. J. Tub., Vol. XXVIII, No. 1

40

ABSTRACTS

Niigata Prefecture in Japan, there were 1,378

new cases in 1974. 24 patients (1.7%) died within one year. Deaths among the tuberculous were 2.5 times higher than actual deaths due to tuberculosis. Of the total deaths from tuberculosis in the Prefecture in one year, 24 were directly due to advanced tuberculous disease with in one year, 26 subsequently because of failure of treatment with drug resistant bacilli, 53 due to cardiopulmonary insufficiency with stable lung lesion and negative sputum and 116 deaths due to non-tuberculous causes wrongly reported as tuberculous deaths. S.P.P. Pulmonary autopsy foldings in patients advanced tuberculosis treated with prolonged and effective chemotherapy H.L. Katz, Bull. Int. Un. Tub.; 1979, 54, 313.

Autopsy findings in 94 patients treated between 1961 and 1976 are reported from Veterans Hospital, New York. 79 patients had negative sputum for more than 3 years and 25 patients for more than 10 years prior to death. In 41 patients cause of death was malignancy. In 17 % of the malignancy deaths upper or lower respiratory tract or eosophagus was involved. Malignancy originated usually in scar tissue or in the fibrous wall of a healed cavity, Histological signs of chronic bronchitis- were present in 75% of the cases. Emphysema with exception of perifocal dilation and rupture of alveolar walls is not related to the healing of tuberculosis. These are independent disease processes. S.P.P. Study of the symptoms of newly diagnosed pulmonary tuberculosis and patients* attitude to the disease and to its treatment

D.J. Girling Bull. Int. Un. Tub.; 1979, 54, 307. In 81 % of the patients reporting at Government chest clinics in Hong Kong cough was the first symptom. In 27 % it was the only complaint. In 15% cough was productive. Haemoptysis was reported by 27%; 11 % of the patients attended a chest clinic as their first source of treatment, another 17% attended a general outpatient department; 53% of the patients went to a private practitioner; 2% to private general hospital; 2% to a private x-ray clinic directly and 9 % to a practitioner of indigenous medicine. S.P.P. Ind. J. Tub., Vol. XXVIII, No. 1

Hepatitis and other adverse reactions to Antituberculosis chemotherapy in perspective

D.J. Girling, Bull. Inter. Un. Tub.; 1980, 55, 8. With modern chemotherapeutic regimens containing one or both of Rifampicin and Pyrazinamide, whether as short-term regimen or regimens of standard duration, given daily or intermittently, adverse reactions are uncommon. They are rarely serious, largely preventable and, when they do occur, rarely give rise to major problems of management. S.P.P. Extra-pulmonary tuberculosis in the United States, 1975-77 L. Farer, A. Lowell and S. Jewell, Bull. Int, Un. Tub.; 1979, 54, 293,

There appears to be an inverse relationship between the tuberculosis case rate and the proportion of cases reported as extra-pulmonary. In states with higher tuberculosis case rates the percentage of extra-pulmonary cases tends to be lower. About 2/3rd of extra-pulmonary cases are pleural, lymphatic or genito-urinary. Lymphatic disease alone contributed about l/4th of the cases. Lymphatic system involvement was most common in children under 5 years followed by meningitis. In the 5 to 14 years age group lymphatic involvement was still the commonest but pleurisy came second. Among young adults and older individuals pleural involvement was the commonest with lymphatic system a close second and genitourinary third. 53% of the cases were males and 47% females, as against 2 : 1 ratio in pulmonary tuberculosis. Lymphatic disease was consistently and significantly more often seen in females than males. The diagnosis was bacteriological]y confirmed in nearly 2/3rd of the cases.

S.P.P.

The risk of infection and disease in contacts with patients excreting mycobacterium tuberculosis sensitive and resistant to Isoniazid M. Sitninel, G. Bungetzianu & C. Anastasatu Bull. Int. Un. Tub.; 1979, 54, 263.

3,189 child contacts of 931 sputum positive pulmonary tuberculosis patients were studied. 676 patients had bacilli sensitive and 255 resistant to INH. Infection rates were 23.8 % amongst the contacts of sensitive patients, 18.9% in contacts of highly resistant cases and 17.4% in contacts of low resistant cases. These percentages in the age group 0 to 4 years were

ABSTRACTS

25.8%, 14.0% and 20.1% respectively. The proportion of severe forms of disease was 4.2% in the sensitive patients’ contacts as against 2.8% in the resistant cases contacts in the 0 to 4 years group. This proves the hypothesis according to which bacilli which have become resistant to INK show a decrease in their pathogenicity, not only in laboratory animals but in human contacts as well. S.P.P. The British Thoracic Association inquiry into the yield from a standardised contact procedure Presented by Dr. A. Sornner on behalf of the Contact Study Sub-Committee of the Research Committee of the British Thoracic Association. Bull. Int. Un. Tub.; 1979, 54, 321.

1,668 close contacts and 2,731 casual contacts of 1,237 freshly diagnosed cases of pulmonary tuberculosis in 37 clinics in U.K. arc reported. 75% of the close contacts were reviewed at one year and 50% at 2 years. The yield from the close contacts is very similar for the Asian and non-Asian (mainly British) communities viz. 3.4% and 3.6% respectively. The yield was about 3 times greater when the index case had a positive sputum smear and about a third when the index case had nonrespiratory disease. Most close contacts were diagnosed at the initial examination but contacts of Asian Index cases had an appreciable morbidity at re-examination at one year or two years. S.P.P. Osteitis caused by BCG vaccination of newborn O. Wasz-Hockert et al, Bull. Int. Un. Tub.; 1979, 54, 325.

128 cases of mild chronic osteitis in BCG vaccinated children have been collected in 15 years in Finland. The rate of BCG osteitis per million vaccinated children was 46 in Finland, 35 in Sweden and 0.6 in 8 other European countries. The clinical picture is typical. Most of the bones involved arc sternum, ribs, tibia, femur and small bones of the hands and feet, the majority of these being on the left side of the body i.e. the site of vaccination. The osteitis was usually seen 8 to 24 months after vaccination amongst the new borns. In 65 cases BCG could be recovered from the lesion. In the remaining 63 cases typing of the tubercle bacilli could not be carried out. S.P.P.

Cost/efficacy and cost benefit of BCG vaccination in France A. Lotte et al, Int. Un. Tub., 1979, 54, 325

Nearly 200,000 children, 4 to JO years of age were followed in France to study the role of BCG vaccination. Morbidity was very low (]/6th) in vaccinated children as compared to unvaccinated children. Assuming that the morbidity from other causes in the vaccinated and unvaccinated would have been equal, it is estimated that vaccination of 100,000 children prevented 373 cases of tuberculosis from 1962 to 1960 and 163 cases from 1966 lo 1976. There fore, BCG vaccination as a preventive measure is less effective now than previously. S.P.P. Intrapleural BCG in operable lung canceer Julia Lowe et al, The Lancet; 1979, i, 11.

92 consenting operated lung cancer patients were randomly allocated to two groups. In one group EGG (1 x IO7 viable units of Glaxo vaccine) was given on the 3rd to 5th post-operative day. 14 days after BCG, 300 mg/day INH was started and continued for 8 weeks. The second group were controls, and were given placebo in place of BCG and INH. The overall survival of the two groups was compared with the log-rank test, and 2-tailed p values were derived. The significance of differing survival rates within sub-groups of patients (according to the pre-operative stage of tumour) was tested with the chi-square test for trend and the logrank test. There were 22 deaths among the 47 BCG patients and 21 deaths among the 44 controls (one case was excluded because lung cancer was not confirmed by histology). After 36 months’ follow up, the pattern of survival curves did not differ materially in the 2 patient groups, nor was there any trend which appeared clinically important. The adverse effects were few. Only half the patients receiving BCG had mild fever lasting for 2 to 3 days. One patient required anti-tuberculous chemotherapy 4 months after surgery for a discharging wound. The patient, however, is still alive and well with no tumour recurrence. There was no significant difference in the long-term survival of patients who developed empyema after surgery. S.P.P.

Ind. J. Tub., Vol. XXVIII, No. 1