Elsevier

Archives of Medical Research

Volume 35, Issue 5, 10 September 2004, Pages 435-441
Archives of Medical Research

Original article
Extrapulmonary tuberculosis: clinical and epidemiologic spectrum of 636 cases

https://doi.org/10.1016/j.arcmed.2004.05.008Get rights and content

Background

The aim of this study was to evaluate the percentage and characteristics of extrapulmonary tuberculosis (EPTB) cases in a Turkish industrial city, Kocaeli (population: 1,203,335) and to illustrate its extent as a serious health problem for this city and country.

Methods

We investigated the results of microbiologic, radiologic, and histopathologic findings of patients with extrapulmonary tuberculosis, retrospectively, who were admitted to four Tuberculous Dispensaries between 1996 and 2000.

Results

Six hundred thirty six cases were diagnosed with EPTB. Three hundred forty five were males (54.2%) and 291, females (45.8%). Mean age of patient cases was 22.5±17.1 years (range, 1–86 years); 41.4% of cases were <15 years of age and 30.9%, between 20 and 39 years of age. Contact history with tuberculosis cases was determined in 242 cases (38%); of these, 194 were <15 years of age (80.2%). The most common form of EPTB was observed to be lymph node tuberculosis (56.3%); of these cases, 256 (71.5%) had involvement in intrathoracic, 92 (25.7%) in cervical, and 10 (2.8%) in axillary lymph nodes. The second most frequent extrapulmonary form was pleural tuberculosis (31.1%). EPTB was diagnosed by histopathologic methods in 229 patients (36.0%) and by microbiologic methods in 27 (4.2%); tuberculin skin test was significantly positive (>10 mm) in 95.5% of patients. When cases were classified according to severity, 87 cases (13.7%) were found severe and 549 (86.3%) as less severe EPTB. Five hundred sixty one cases (88.2%) lived in urban areas and 75 (11.8%), in rural areas.

Conclusions

EPTB is very common in early adulthood in the Kocaeli region, with lymph nodes the most common localization.

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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