Aust. N.L J Med (1981), 11, pp 651 653 -___

Presentation of Pulmonary Tuberculosis

P. Holmes* and L. Faulkst

From the Repatriation General Hospital, West Heidelberg, Victoria

Abstract: Presentation of pulmonary tuberculosis. P. Holmes and L. Faulks. Aust. N.Z. d . Med., 1981,11, PP. 651-653.

A study was made of the presenting features of 700 consecutive Australian patients with pulmonary tuberculosis. A clinical diagnosis of pulmonary tuberculosis was suspected at the time of first presentation in only 52 patients and the initial provisional diagnosis was that of a non-tuberculous chest condition in a further 32 patients. In another 16 there was a delay in diagnosis because pulmonary tuberculosis was suspected only after chest X-rays were taken for screening purposes-for example, prior to elective surgery, A non-cavitating lesion in an upper lobe was the radiological appearance most often associated with failure to suspect tuberculosis at the time of presentation, The most common symptoms or change in pre-existing chest complaints were cough (55), loss of weight (52) and shortness of breath (43) followed by fever or night sweats (23) and haemoptysis (10) while 16 were asymptomatic.

Key Words: Pulmonary tuberculosis -~Non-cavilating lung lesion- Cough -- Weight Loss Delayed diagnosis.

Introduction Morbidity and mori%ity from pulmonary tuber- culosis had fallen for many years but recent studies show an increase in new cases from the noii-immigrant, non-refugee, Victorian com- munity.’ Since the suspension of the compulsory mass X-ray survey in Victoria in 1976, more than half of the notifications of tuberculosis have originated from general hospitals (29’7%) and private practitioners (24.27;). Thus the hospitals will continue to play an important role in the

______ _ _ _ _ _____ _____ ‘Visiting Specialist (Chest Disease). tSenior Specialist (Chest Diseases). Correspondence: Dr. L. Faulks,

Senior Specialist (Chest Diseases). Repatriation General Hospital. West Heidelberg, Victoria 3081

Accepted for publication: 24 June 1981

initial diagnosis of tuberculosis. The aim of this paper is to study the presenting features of Australian patients with newly diagnosed pul- monary tuberculosis in a teaching hospital. Factors associated with delays in diagnosis are also explored.

Methods Beginning in 1975 we studied 100 consecutive patients with bacteriologically proven active pulmonary tuberculosis admitted to the Repatriation Ciencral Hospital, Heidelberg. There were no migrants o r refugees. Most were new cases but some had reactivation of previously treated disease. Patients were groupcd according to the mode of presentation, and analysed t o i - the presencc of new symptoms o r for changes in prc-existing chest complaints (Table 1 ). Chest X-ray patterns were also recorded (Table 2). Possible predisposing factors including exce.;sivc alcohol intake. drugs. and other illnc were noted.

Results There were 97 males and three females. The ages of the patients ranged from 42 to 85 (mean 5 8 . 6 years). A clinical diagnosis of pulmonary tuber- culosis was made at presentation in only 52 patients. I n the remaining 48, the diagnosis was eventually obtained after exclusion of other suspected chest diseases or following the chance discovery of X-ray changes suggesting pul- monary tuberculosis. The interval between admission and diagnosis in these patients ranged from I 4 weeks (mean 9 days).

The patients’ symptoms are shown in Table 1 in which they are grouped according to the method of diagnosis. Sixteen patients denied any symptoms at the time of presentation, Irrespec- tive of the mode of presentation, cough, weight loss and dyspnoea were the symptoms which predominated. Haemoptysis was uncommon. The X-ray findings are shown in Table 2. Ten per cent of the cases had lower zone disease on chest X-ray. In one of these patients the disease appeared to be confined to the lower zone. The lung parenchyma was involved in seven of the eight patients with pleural effusions.

652 HOLMES AND FAULKS VOL. 1 1 , NO. 6

TABLE 1 Symptoms and mode of presentation

_____.__ -______ - Clinical diagnosis made at time of presentation

Diagnosis not made a t time of presentation

. . . . . . . . . . . . .- . -. - ....... - . . .

Symptoms

Cough. sputum Lo\\ of weight Dyspnoea Fever night sweats Lassitude weakness Pleurisy Anorexia Asymptomatic Haemoptlsis

Group I * ( I1 = 27)

No ("")

21 (77) 20 (74) 13 (48) 8 (29) 8 (29) 7 (26)

0 ( 0 ) 6 (22)

8 (29)

Group 2+ ( I? = 25)

y o (clJ

15 (60) 15 (60) I 1 (44) 3 (12) 5 (20) 3 (12) 3 (12) 5 (20) 0 (0)

Group 4**

h o (<'d

6 (38) 7 (44) S (31) 4 (25) I ( 6 ) 2 (12) 2 (12) 5 (31) 1 ( 6 )

(f7 = 16) Total

( f l = 100)

5 5 52 43 23 22 IS 1s 16 10

- ._ . . . . . . . . . . . . . . . . . -

*Group 1: Symptoms and chest X-ray appearance suggested diagnosis of active pulmonary tuberculosis at time of presentation

tGroup 2: Recent change in radiological lesion in patients under annual review for previous proven or suspected pulmonary

$Group 3: Patients under investigation for respiratory disease but tuberculosis not considered in initial differential diagnosis.

**Group 4: No acute or subacute respiratory condition suspected at presentation. Tuberculosis considered only after chest X-ray

(27?$.

tuberculosis (2516).

Tuberculosis often revealed following routine microbiological screening tests (32";,).

taken for screening purposes e.g. pre-operatively ( 1 6 " ~ ) .

TABLE 2 Chest X-ray patterns

~ ~~

Clinical diagnosis made at time of presentation

Diagnosis not made at time of presentation

- - .._ . _. - . - - - .. - - . - - ______ _ _ " Group 1* Group 2f Group 3: Group 4** /a

Non-cavitating 4 7 12 5 28 CdVltdtlllg 2 1 1 0 4

Yon catitating 2 10 8 2 22 Cavitating 1 2 1 0 4

Non-eaL itdtlng 9 2 I 5 27 Cdvitating 2 4 I 1 8

Right lower zone +t 1 0 1 0 2 Left lower zone tt 2 1 1 1 5 Bilateral lower zone tt 3 0 0 3 6 Pleural effusion 6 2 0 0 8 Hilar I) mphadenopathy 0 0 1 0 1

- -_ _ _ __ -

Right U 2 lesion

Left U 2 lesion

Bildteral c iesions

-- - - - . -- - _ - ___ -_--_ ____ __ __ *, 7, 1, ** See Table 1 tt No associated cavitation

Factors predisposing to tuberculosis were common. Sixty-eight patients smoked regularly and forty-three were considered to drink alcohol excessively. Of these, 31 (72%) had a broken marriage and 12 (28%) were single. Only 11 patients described contact with known cases of tuberculosis. Seven patients had previously

undergone partial gastrectomy, four patients were receiving treatment with oral corticosteroid drugs, three patients suffered from diabetes mellitus and two were found to have co-cxisting lung carcinoma.

There were 1 1 negative Mantoux tests in the 64 patients tested.

DECEMBER 198 1 PULMONARY TUBERCULOSIS 653

Discussion The predominance of middle aged males seen in this group was similar to other studies.2.4'5 The findings of negative Mantoux tests in 177; of patients with active tuberculosis is also in accordance with other studies.23 '. N o analysis of the likely causes for this was undertaken. Severe tuberculosis, old age and excessive alcohol consumption may have contributed. Thus the diagnosis of pulmonary tuberculosis should never be excluded on the grounds of Mantoux negativity alone.

The making of a diagnosis of pulmonary tuberculosis is often delayed in hospital patients.2 '. ' The hospital in which these patients were treated has maintained full laboratory and treatment facilities for tuberculosis for over 30 years and the staff have had a high level of awareness of the disease. Delays occur most frequently in patients managed in non- respiratory units, particularly if the presentation is unusual. It is interesting to note that tuber- culosis was always suspected in the patients presenting with pleural effusion.

This survey suggests that middle-aged smoking male subjects with alcoholic problems and marital upsets should be carefully studied for the presence of tuberculosis even if chest X-ray appearances do not immediately suggest this diagnosis. Particular attention should be paid to patients having other predisposing factors. These include the use of immunosuppressive drugs, diabetes and previous gastrectomy. The association of tuberculosis and carcinoma of the lung should also bt?emembered.6 Special atten-

tion should be paid to patients who have been treated for active tuberculosis in the past without adequate chemotherapy. The proportion of primary tuberculosis in the adult is likely to increase in the future4 resulting in a greater tendency for tuberculosis to present as pleural effusion, hilar adenopathy and lung disease not predominantly with apical distribution.

The need for continuing vigilance and a high degree of awareness of pulmonary tuberculosis is emphasised. The finding in this study that only 27 patients presented because of symptoms attributed to tuberculosis and furthermore, that the most common symptoms at presentation (cough, loss of weight and dyspnoea) are non- specific, emphasises the importance of remem- bering tuberculosis in order to decrease the delay in the diagnosis of this important disease.

Acknowledgements We thank Dr. A. H. Campbell for his support and Dr. P. R. Bull for his suggestions in preparation of the manuscript.

References I. Health Commission of Victoria Reports of the activities of the tuberculosis

branch, 1978 and 1979. 2. MacGregor RR. A year's experience with tuberculosis in a private urban

teaching hospital. Am J Med 1975;58:221 -7. 3. Stack BHR. Diagnosis of tuberculosis in a general hospital. Br Med J

1971;4610 14. 4. Khan MA, Kuvnat DM, Bachus B et a!. Clinical and roentgenographic

spectrum of pulmonary tuberculous m the adult. Am J Med 1977:62:31 -8. 5 Greenbauin M, Beyt BE. Murray PK. The accuracy of diagnosing pulmonary

tuberculosis a1 il teaching hoqxtal. Amer Rev Respir Dis 19XO;I21:477-.81 h. Kaplan MH, Aimstrong I), Rosen P Tuberculosis complicating neoplastic

disease: a review of 201 cases. Cancer 1974:33:850-8. 7 . Nasli DR. Douglass JE. Ancrgy in active pulmonary tuberculosis A

conip;iiiso" betw&37 positive r i d negative riliiciors and ai l evaluation of YIU. and 2507.11. skin test doses. Chest 1980.77.32 7

8 McCullwh DK. Mdlone DNS. I'rt'sentation of tuberculosis In an acute inedical unit. Lancet 1980;1:70? 3