Original articleExtrapulmonary tuberculosis: clinical and epidemiologic spectrum of 636 cases
Introduction
Tuberculosis (TB), one of the oldest diseases known to mankind, remains one of the most fatal diseases in the world. Eight million persons contract tuberculosis each year, three million of whom will die from the disease (1).
Incidence of tuberculosis rises under individual conditions such as leukemia, HIV, or diabetes, which depress the immune system, and under socioeconomic conditions such as war, poverty, overcrowding, and migration (2). Incidence of tuberculosis infection is low in Western European countries; nonetheless, it unfortunately remains a major health problem in Turkey. According to data from the Turkish Directorate of the Struggle Against Tuberculosis, incidence of tuberculosis between 1996 and 2000 was 33.1, 31.5, 30.3, 27.0, 26.2 per 100,000, respectively, per successive year (3); thus, infection rate remains high.
Extrapulmonary tuberculosis (EPTB) increases in parallel fashion with the rise in incidence of pulmonary tuberculosis. The proportion of EPTB cases with regard to all tuberculosis cases varies from country to country. This proportion was 8% in the U.S. in 1964, increasing to 17.5% in 1986. In a study carried out in England in 1988, this figure was 32% in indigenous population and 57% in immigrant populations (4). In Germany, it was 16.9% (5), in Spain 33.4% (6), and in China, 9.7–11.8% (7).
Because tuberculosis is a common public health problem, it is considered to fall within the framework of the national control programs in all countries. In Turkey, the Directorate of the Struggle against Tuberculosis is affiliated with the Ministry of Health, which has a large organizational network. Dispensaries for fighting tuberculosis are the leading organizations in this campaign in Turkey. At these dispensaries—the number of which has reached 272 throughout the country—lung tuberculosis is diagnosed, drugs are distributed at no cost to persons with tuberculosis, cases are monitored, family contacts are examined, and tuberculin skin tests, chemoprophylaxis, and bacille Calmette-G (BCG) vaccinations are carried out. Cases requiring hospitalization are referred to regional hospitals and after treatment completion, continue to be monitored by the dispensaries.
Kocaeli, the third largest city in the Marmara region, is an industrial city established on European-Asian land and railroads. It has a population of 1,203,335 persons and four tuberculosis dispensaries serve the entire population. However, as it is the most industrialized region in Turkey, migration is common. In one of our studies, total combined drug resistance was determined as 37.8% in Kocaeli (8).
We reviewed the general spectrum of cases diagnosed with EPTB and monitored cases seen at dispensaries in the region with the aim of establishing a standard incidence value for the region and the country.
Section snippets
Study population
Records of 2,533 cases referred between 1996 and 2000 to dispensaries in the Kocaeli region and diagnosed with tuberculosis were reviewed retrospectively; of these, 775 EPTB cases were determined. Some files could not be obtained (due to relocation outside the region, death, lack of records, etc.); as a result, only 636 EPTB cases for whom records were available were included in this study.
Study design
World Health Organization (WHO) criteria were used for case definition (9). Accordingly, cases having
Results
In the city of Kocaeli, Turkey, from 1996 to 2000, the number of persons diagnosed with tuberculosis and for whom treatment was initiated in dispensaries was 2,533, corresponding to an average incidence of 42.4 cases/100,000 inhabitants. Of these 2,533 cases, 775 (30.6%) had extrapulmonary tuberculosis (Table 1) (Figure 1). Characteristics of the 636 study cases (345 male, 291 female) with EPTB whose records were available are shown in Table 2. Mean age of cases was 22.5 ± 17.1 years (range,
Discussion
In this study the ratio of EPTB to all TB cases was found as 30.6%. In Turkey, testing for HIV is not routinely done in tuberculosis dispensaries; therefore, no information on HIV status was present in the records. According to reports from the Ministry of Health, 431 people were diagnosed with AIDS and 998 HIV seropositive cases were detected between 1985 and 2001 in Turkey. In the region of our investigation, five AIDS and seven HIV-seropositive cases were reported in the same period;
Acknowledgments
The authors would like to thank these physicians working at the Tuberculosis Dispensaries for their enthusiastic participation: Mustafa Uzar, M.D.; Müfide Akbulut, M.D.; Metin Eroğlu, M.D.; Aysun Dinç, and Joan Walker.
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