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Year : 2017 | Volume : 5 | Issue : 1 | Page : 21 - 24  


Original Articles
Clinico- Social profiles and Probable indicators of Skeletal Tuberculosis in Karimnagar district, Telangana

AA Kameswar Rao 1, A SaiRam 2, Suresh J3 , Nilesh B4

1 Retired Professor of Community Medicine, Malla Reddy Institute of Medical Sciences, Hyderabad

2Assistant Professor, Kamineni Academy of Medical Sciences, Hyderabad

3& 4 Resident, Pratima Institute of Medical Sciences, Karimanagar

Corresponding Author:

Dr. AA Kameswar Rao

Email: avasarala46@gmail.com

ABSTRACT:

Back ground: Skeletal tuberculosis could lead to disabling and painful states of bones and joints affecting the quality of life.

Objective: To study the clinico-social profiles of Skeletal Tuberculosis (SKTb) in Karimnagar district of Telangana state

Methods: A hospital based cross-sectional study was carried out using purposive sampling. Three doctors collected the data from 100 patients suffering from SKTb using a pretested questionnaire on the social variables, clinical presentations and probable indicators and analyzed. Group talks were conducted with patients for imparting necessary heath knowledge regarding prevention of further complications.

Results: Overall prevalence of SKTb was about 33%. SKTb was more seen among males (58%). Tuberculosis of Spine was the leading bone disease (52%) followed by that of knee (22%) and hip (16%). Mean age affected was 45-65 years (39%).SKTb affected largely lower and middle class people (90%), less educated people (92%) non-executives (92%) Majority of patients (62%) were tuberculin positive .One third of patients (33%) had past history of pulmonary tuberculosis. Thirty percent of patients gave family history of tuberculosis.

Conclusion: SKTb was found to be related with the past history of pulmonary tuberculosis, family history, and tuberculin positivity. Intensifying health education about these probable indicators is worth trying among the patients families and people at risk to prevent SKTb.

Key Words: Skeletal tuberculosis, Clinico- social profiles, Karimnagar district

INTRODUCTION:

Skeletal tuberculosis accounts for 30% of the tuberculosis occurring at extra pulmonary sites. [1] And it is a major source of osteo-articular complications. [2] Disability limitation, i.e. prevention of further complications can be done if the social factors operating in the patients and clinical presentations are well understood. It will be easier for the further management of the patients with educational intervention and clinical planning.

In addition, it was particularly tried to find out whether the patients past history of suffering from pulmonary tuberculosis or the presence of Monteux positivity and presence of pulmonary tuberculosis in family members have got any relationship with the present SKTb. If the relationship was present, it will be possible to prevent SKTb by the patients and family members by paying more attention to these probable indicators.

With the above intensions for searching for a possibility of probable indicators to prevent SKTb in future and preventing further complications for SKTb, this study was conducted not only to know the clinical and social profiles and but also relationship of past history, family history and Monteux positivity with in this region of Karimnagar district.

MATERIAL & METHODS:

This cross-sectional study was conducted for two months in the year 2008 in Karimnagar city. Ethical committee approval was obtained prior to the study. Reference population was 300 patients (outpatient and in-patients) who attended one teaching hospital and two orthopedic hospitals in the city. Study population was 100 patients who were diagnosed as suffering from SKTb by the two orthopedicians. Diagnosis was made by them basing on clinical picture supported X-ray, CT scan, ESR, and biopsy. [3]

Data on clinical and social variables and probable indicators was collected from these 100 patients with SKTb by three doctors of the department of community medicine using a predesigned questionnaire. The questionnaire contained questions on social variables (occupation, family history of pulmonary tuberculosis in the family members, past history of pulmonary tuberculosis in the patient, socioeconomic status, rural –urban status, immunization status etc.) and clinical profile (deformity, signs and symptoms, neurological involvement, site affected, structures affected etc.).The questionnaire was pretested in 10% of patients and revised. Following case definitions were utilized for the study:

For Tb spine, patients presenting with complaints like pain and stiffness and x-ray finding suggestive of reduction in disc spaces and para vertebral abscesses, with CT findings suggestive of fragmentary vertebral destruction. Additional investigations supporting the diagnosis are Monteux test, ESR and biopsy.

For Tb knee, patients present with complaints like pain, swelling, difficulty in walking, and x-ray finding suggestive of juxtra- articular lytic lesions, reduction in joint spaces. Additional investigation supporting diagnosis is Monteux test, ESR, and biopsy.

For Tb hip, patients with pain, difficulty in getting up and walking, CT scan showing lytic lesions , articular space reduction with raised ESR and Monteux testing and biopsy.

Others included tuberculous osteomyelitis of calcaneum, radius and ankle joint.

Data was analyzed using Epi infoVersion 6.

Group talks, weekly once, were conducted with patients about the causes of their disease (stressing more on relevance of past history, family history, Tuberculous infection), how to manage the disability and how to prevent further Complications. Family members were also included.

RESULTS:

The overall prevalence of SKTb is about 33%. Results were classified under three headings viz. clinical profile, social profile and probable indicators.

Clinical profile:

Most common type of pathology for all SKTb was fragmentation type (74%) followed by lytic l type. (18%) ( Table 1) Tuberculosis of Spine was the leading bone disease (52%) followed by tuberculosis of knee (22%) and hip (16%). (Table 2) Most common clinical symptoms/signs were pain, swelling and deformity. (Table 3) Only 35% of Tb spine patients suffered from pulmonary tuberculosis got treated with anti-tuberculosis treatment.

Social profile:

Tuberculous bone disease occurred after 25 years of age, increasing in incidence as age was advancing. Mean age affected was 45-65 years (39%). Tuberculous osteomyelitis was occurring earlier, 15-25 years of age, when compared to Tb of spine, Hip and knee. (Table 4) Tuberculous bone disease was more seen among males (58%) than in females (42%). All varieties of Tb were more seen in males.(Table 4)

It affected largely lower and middle class people (90%), (p=0.315; not significant); less educated people (92%) non-executives (92%) and (p= 677; not significant) and poor income workers (95%) and rural people in the study population. (Tables 5, 6, 7, 8)

Probable indicators

Majority of SKTb patients (62%) patients were positive for tuberculin test. (Table 9) (p = 0.038; significant) Almost one third of patients (33%) were having past history of pulmonary tuberculosis. (Table 10) (p=0.0623; not significant) Thirty percent of patients gave family history of tuberculosis in their families. (Table 11) (p=0.860; not significant)

DISCUSSION:

The study was discussed under the following headings

Principal findings: Overall prevalence of SKTb was more than a third of reference population. Tuberculosis of spine was the leading form of skeletal tuberculosis followed in ranking by that of knee and hip. Commonest pathology of SKTb was bone fragmentation and lysis. [4, 5] SKTb was more related (not significantly) with rural people, less educated and belonging to lower classes and but associated significantly with Monteux positivity.

Clinical profile: Clinical picture was very much similar to all forms of SKTB with a little difference. All SKTb were almost presenting with pain, swelling, fever and disability in most of the studies.

Signs and symptoms: Commonest symptom in this study was pain, associated with fever and swelling similar to the studies by Ruiz G [6], Mariconda M, [7] Fancourt GJ. [8] A cold abscess in one patient and sciatica nerve involvement in one patient was also observed as observed by Agarwal RP[9] but Mariconda M et al [7]observed higher incidence( 13.9%) of neurological affection in their study. Tuberculous spine: This leading morbidity (33%) coincides with high incidence observed Agarwal RP [9] et al (48.97%) but Kim SJ et al [10] found it rare in their study. Caries spine was observed with gibbus in the thoracic region in this study as also observed by Rodriguez-Gomez M et al. [11]While Tuli SM.[12] has reported 3% of kyphoscoliosis, it was seen less ,only one percent in the present study.

Tuberculous knee and tuberculosis of hip were also common ailments observed in the study usually associated with painful swelling and walking difficulty.

Prevalence and Ranking order: Lot of variation was observed both in the prevalence of disease and its ranking order of occurrence. While few of the studies by Leibe H, [1]Pertuiset E[14]quoted very low figures and stating rare, majority studies by Rodriguez-Gomez M , [11]Schwartz Y, [15] Netval M [16] Huang J. [17] Were supporting the present study with very high magnitude. Regarding ranking also, there was a little discrepancy between the studies. While studies by, Schwartz Y,[15]Netval M[16]supported the same ranking of spine, knee and hip sequence as in this study, Leibe H[13]study places TB Hip in the second rank and Tb knee in the third position. Age & sex preferences: Ages affected were widely varying in the studies. While the mean age in the present study was 45-65 years, more or less similar to that observed by Leibe H, [13] (mean age 7th decade) and Rodriguez-Gomez M (mean age 60.3 years) studies, [11]some studies by Agarwal RP at 20-30 yrs, [9] Fancourt GJ [8] at 40.2 years and Schwartz Y highest in 3rd decade . [15] reported occurrence of SKTb at younger ages, Males were more affected in this study like in Agarwal RP study [9] probably due to more stress on weight bearing joints due to more manual work in males.

Education and Social status: This factor seems to be related to the disease as the disease mostly observed in lower class, uneducated and rural people in this study as well as Agarwal study. [9] This may be due to the role played by poverty complex (poverty, illiteracy and ignorance of prevention of disease) which is more commonly seen in rural population of Karimnagar district a well-known for its backwardness.

Probable indicators: High and significant Monteux positivity with almost third of the patients with past history and family history were correlating with other studies. They are pointing to the occurrence of bony tuberculosis and can be used as useful indicators for prevention.

Monteux positivity: In most of the studies, Ruiz [6] (83% +ve)Rodriguez-Gomez M [11] (76% positive) including the present one (63% +ve), tuberculin test positivity was significantly observed among the patients suggesting that it can be an useful pointer or indicator for early detection of SKTb and prevention. Past history of pulmonary tuberculosis in one third of cases in this study also adds to the suspicion of development of SKTb as it appears to be an important predisposing factor stressed by Ruiz G et al [6]and by Halsey JP et al( positive in 50% of his patients) [18] Family history of tuberculosis in the family members of 30% of patients provided some more support to the occurrence of SKTb

CONCLUSION:

SKTb is found to be related with the past history of pulmonary Tuberculosis, family history, tuberculin positivity. Intensifying health education about these probable indicators is worth trying among the patients families and people at risk to prevent SKTb

REFERENCES:

  1. De Vuyst D, Vanhoenacker F, Gielen J et al. Imaging features of musculoskeletal tuberculosis. 1: Eur Radiol. 2003;13(8):1809-19
  2. Gonzlez-Gay MA, Garca-Porra C, Cereijo MJ et al. The clinical spectrum of osteo-articular tuberculosis in non-human immunodeficiency virus patients in a defined area of North-Western Spain (1988-1997). Clin Exp Rheumatol. 1999;17(6):663-9
  3. Ridley N, Shaikh MI, Remedios D et al. Radiology of skeletal tuberculosis. 1998 Nov;21(11):1213-20
  4. Jain R, Sawhney S, Berry M. Computed tomography of vertebral tuberculosis: patterns of bone destruction; Clin Radiol. 1993;47(3):196-9
  5. Cotten A, Flipo RM, Drouot MH et al. Spinal tuberculosis: [Study of clinical and radiological aspects from a series of 82 cases] J Radiol. 1996;77(6):419-26
  6. Ruiz G, Garca RJ, Gerri ML et al. Osteoarticular tuberculosis in a general hospital during the last decade. Clin Microbiol Infect 2003;9(9):919-23
  7. Mariconda M, Cozzolino A, Attingenti P et al. Osteoarticular tuberculosis in a developed country. J Infect 2007;54(4):375-80
  8. Fancourt GJ, Ebden P, Garner P et al. Bone tuberculosis: results and experience in Leicestershire Br J Dis Chest. 1986;80(3):265-72
  9. Agarwal RP, Mohan N, Garg RK et al. Clinic social aspect of osteo-articular tuberculosis. J Indian Med Assoc. 1990;88(11):307-9
  10. Kim SJ, Seok JW, Kim IJ et al. Multifocal Potts disease (tuberculous spondylitis) incidentally detected on Tc-99m MDP bone and Ga-67 citrate scintigraphy in a patient with diabetes. Clin Nucl Med 2003;28(4):286-9
  11. Rodriguez-Gomez M, Willisch A, Fernandez-Dominguez L et al. Tuberculous spondylitis: epidemiologic and clinical study in non-HIV patients from northwest Spain, Clin Exp Rheumatol 2002;20(3):327-33
  12. Tuli SM. Comment in: Severe kyphotic deformity in tuberculosis of the spine. Int Orthop. 1996;20(4):271. Int Orthop 1997;21(6):417.
  13. Leibe H, Khler H, Kessler P. Osteoarticular tuberculosis: Review - current status of diagnosis and therapy] Zentralbl Chir 1982;107(5-6):322-42
  14. Pertuiset E, Beaudreuil J, Liot´┐Ż F et al. Spinal tuberculosis in adults. A study of 103 cases in a developed country, 1980-1994. Medicine (Baltimore) 1999;78(5):309-20
  15. Schwartz Y, Dolev E. Osteoarticular tuberculosis in a general hospital] Harefuah 1991;15;121(10):357-9
  16. Netval M, Hudec T, Hach J. [Different forms of tuberculous hip arthritis (case study)] Acta Chir Orthop Traumatol Cech 2007;74(3):206-9
  17. Huang J, Shen M, Sun Y. [Epidemiological analysis of extra pulmonary tuberculosis in Shanghai] PMID: 11372385 [PubMed - indexed for MEDLINE]
  18. Halsey JP, Reeback JS, Barnes CG. A decade of skeletal tuberculosis. Ann Rheum Dis.1982 Feb;41(1):7-10

Table 1: Distribution of Tb bone disease as per its pathological type

Type

Male

Female

Total

N

%

N

%

N

%

Fragmentary

40

40

34

34

74

74

Osteolytic

10

10

08

08

18

18

Sub-periosteal

04

04

00

00

04

04

Lytic with sclerotic margins

04

04

00

00

04

04

Total

58

58

42

42

100

100

Table 2: Distribution of Tb bone disease as per its location

Location

Male

Female

Total

N

%

N

%

N

%

Tb spine

34

34

18

18

52

52

Tb knee

09

09

13

13

22

22

Tb hip

09

09

07

07

16

16

Osteomyelitis of long bones

03

03

02

02

05

05

Other

03

03

02

02

05

05

Total

58

58

42

42

100

100

Table 3: Distribution of study subjects as per sign/symptom

Type

Pain

Swelling

Fever

Neurological

Abscess

Deformity

Spine

22

06

06

01

01

16

Knee

09

03

02

01

01

00

Hip

16

00

02

02

00

02

OSM

03

01

01

00

00

00

Other

03

01

01

00

00

00

Table 4: Distribution of Tb bone disease as per age and sex

Age (yrs)

Tb spine

Tb hip

Tb knee

OSM

Other

M

F

M

F

M

F

M

F

M

F

14-25

0

0

0

0

0

0

1

1

2

1

25-45

12

3

4

5

4

2

1

1

1

1

45-65

10

12

3

6

3

4

1

0

0

0

65-85

12

3

2

2

2

1

0

0

0

0

Table 8: Urban Rural distribution of SKTb

Type

Urban

Rural

Total

Tb spine

16

36

52

Tb knee

06

16

22

Tb hip

07

09

16

OSM

03

02

05

Other

02

02

05

Total

34

66

100

X2 = 2.949, p = 0.566

Table 9: Distribution of Tb bone disease as per Monteux test status

Monteux test status

Male

Female

Total

N

%

N

%

N

%

Positive

31

31

31

31

62

62

Negative

27

27

11

11

38

38

Total

58

58

42

42

100

100

X2 = 4.2865, p = 0.038

Table 10: Tb bone disease as per past history of pulmonary tuberculosis

Past history

Male

Female

Total

N

%

N

%

N

%

Positive

18

18

15

15

33

33

Negative

40

40

27

27

67

67

Total

58

58

42

42

100

100

X2 = 0.281, p = 0.860

Table 5: Distribution of Tb bone disease as per socio-economic status

Socio-economic status

Male

Female

Total

N

%

N

%

N

%

Higher

08

08

02

02

10

10

Middle

12

12

11

11

23

23

Lower

38

38

29

29

67

67

Total

58

58

42

42

100

100

X2 = 2.307, p = 0.315

Table 6: Distribution of Tb bone disease as per educational status

Educational status

Male

Female

Total

N

%

N

%

N

%

Primary

10

10

08

08

18

18

Secondary

07

07

03

03

10

10

Collegiate

03

03

03

03

06

06

Professional

02

02

00

00

02

02

Illiterate

36

36

28

28

64

64

Total

58

58

42

42

100

100

X2 = 2.322, p = 0.677

Table 7: Distribution of Tb bone disease as per occupational status

Occupational status

Male

Female

Total

N

%

N

%

N

%

Professional

02

02

00

00

02

02

Managerial

03

03

03

03

06

06

Skilled

11

11

08

08

19

19

Unskilled

22

22

10

10

32

32

Unemployed

20

20

21

21

41

41

Total

58

58

42

42

100

100

X2 = 4.555, p = 0.336

Table 11: Tb bone disease as per family history of pulmonary tuberculosis

Family history

Male

Female

Total

N

%

N

%

N

%

Positive

17

17

13

13

30

30

Negative

41

41

29

29

70

70

Total

58

58

42

42

100

100

X2 = 0.031, p = 0.860





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