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Treatment of Tuberculosis: New Case Case Studies Module 7A2 – March 2010.

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Presentation on theme: "Treatment of Tuberculosis: New Case Case Studies Module 7A2 – March 2010."— Presentation transcript:

Evaluation Questions Note: If not used for testing purposes, evaluation questions may be used in slide format inserted within or at the end of each module.

ISTC Training Modules 2008 Your name Institution/organization Meeting Date.

Initial Treatment of Tuberculosis

Your name Institution/organization Meeting Date. Introduction.

June 2004 HITCH Training Slide Set #3 Special Considerations in Antiretroviral Therapy.

TREATMENT OF TUBERCULOSIS, 2003

Tuberculosis in Children: Prevention Module 10C - March 2010.

World Health Organization TB Case Definitions

Case Finding and Diagnosis Module 5 – March 2010.

Treatment of Tuberculosis: New Case Module 7A – March 2010.

In the name of God Fariba Rezaeetalab Assistant Professor.

TB. Areas of Concern TB cases continue to be reported in every state Drug-resistant cases reported in almost every state Estimated million persons.

Why do we test? 1.We want to prevent an outbreak of Tuberculosis in our campus community 2.We want to find those that are affected and get them treated.

Diagnosis of TB.

Unit 5: IPT Isoniazid TB Preventive Therapy

Nurses SOAR! Training Curricula Series

Plans for Diagnosis and Management of Acute Pyelonephritis.

 Pulmonary Tuberculosis BY: MOHAMED HUSSEIN. Cause  Caused by Mycobacterium tuberculosis (M. tuberculosis)  Gram (+) rod (bacilli). Acid-fast  Pulmonary.

Tuberculosis (T.B.) Randy Kim.

TB 101: TB Basics and Global Approaches. Objectives Review basic TB facts. Define common TB terms. Describe key global TB prevention and care strategies.

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• Published: 10 September 2022

Living with tuberculosis: a qualitative study of patients’ experiences with disease and treatment

• Juliet Addo 1 ,
• Dave Pearce 2 ,
• Marilyn Metcalf 3 ,
• Courtney Lundquist 1 ,
• Gillian Thomas 4 ,
• David Barros-Aguirre 5 ,
• Gavin C. K. W. Koh 6 &
• Mike Strange 1  

BMC Public Health volume  22 , Article number:  1717 ( 2022 ) Cite this article

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Although tuberculosis (TB) is a curable disease, treatment is complex and prolonged, requiring considerable commitment from patients. This study aimed to understand the common perspectives of TB patients across Brazil, Russia, India, China, and South Africa throughout their disease journey, including the emotional, psychological, and practical challenges that patients and their families face.

This qualitative market research study was conducted between July 2020 and February 2021. Eight TB patients from each country ( n  = 40) completed health questionnaires, video/telephone interviews, and diaries regarding their experiences of TB. Additionally, 52 household members were interviewed. Patients at different stages of their TB treatment journey, from a range of socioeconomic groups, with or without TB risk factors were sought. Anonymized data underwent triangulation and thematic analysis by iterative coding of statements.

The sample included 23 men and 17 women aged 13–60 years old, with risk factors for TB reported by 23/40 patients. Although patients were from different countries and cultural backgrounds, experiencing diverse health system contexts, five themes emerged as common across the sample. 1) Economic hardship from loss of income and medical/travel expenses. 2) Widespread stigma, delaying presentation and deeply affecting patients’ emotional wellbeing. 3) TB and HIV co-infection was particularly challenging, but increased TB awareness and accelerated diagnosis. 4) Disruption to family life strained relationships and increased patients’ feelings of isolation and loneliness. 5) The COVID-19 pandemic made it easier for TB patients to keep their condition private, but disrupted access to services.

Conclusions

Despite disparate cultural, socio-economic, and systemic contexts across countries, TB patients experience common challenges. A robust examination of the needs of individual patients and their families is required to improve the patient experience, encourage adherence, and promote cure, given the limitations of current treatment.

Peer Review reports

Tuberculosis (TB) is a communicable infectious disease affecting around one quarter of the world’s population [ 1 ]. The ‘BRICS’ countries of Brazil​, Russia, India, China, and South Africa account for 47% of the total number of TB cases annually [ 1 , 2 , 3 ].

Caused by the bacillus Mycobacterium tuberculosis , around 5–10% of those infected will develop active disease. In 2019, 10 million new active cases and 1.4 million deaths were reported [ 1 ]. In 2020, the coronavirus disease 2019 (COVID-19) pandemic severely impacted the reporting of new cases and impeded diagnosis and treatment [ 3 ]. Treatment for multidrug-resistant TB (MDR-TB) also declined by 15% (from 177,100 in 2019 to 150,359 in 2020), with only about a third of patients who needed this treatment obtaining access [ 3 ].

Ambitious targets to end the TB epidemic by 2035 were established in 2015 by the WHO’s End TB Strategy [ 4 ], aligned with the United Nations Sustainable Development Goals [ 5 ]. In 2018, a United Nations General Assembly High-Level Meeting on Tuberculosis resulted in a Political Declaration on Tuberculosis, committing to end TB globally by 2030 [ 6 ]. Achieving these goals requires more equitable deployment of existing measures, and the development of new tools for TB prevention, diagnosis and treatment [ 7 ]. Progress towards ending TB also demands that interventions are aligned to patients’ experiences and address the challenges that they face [ 8 , 9 ].

TB typically involves the lungs (pulmonary TB) and is acquired via inhalation of droplet nuclei in the air following exposure usually over several hours. Close contact and the infectiousness of the source patient are key risk factors for the infection of tuberculin-negative persons [ 10 ]. Current treatment of drug-susceptible TB requires combination therapy consisting of an intensive phase of 2 months of isoniazid, rifampin, pyrazinamide, and ethambutol, followed by a continuation phase of 4 months of isoniazid and rifampin [ 11 ]. Directly observed therapy (DOT) is recommended to ensure adherence to the complex regimen and to deter the emergence and spread of MDR-TB. Treatment is successful in around 85% of patients following 6 months’ therapy [ 1 ]. Also, individuals can become non-infectious within two weeks of treatment initiation, restraining disease transmission [ 1 ]. Thus, prompt initiation of therapy is important for both the patient and their close contacts. However, the management of TB is complicated by the increasing prevalence of MDR-TB, which requires prolonged and complex therapy, and is more likely to be associated with poor outcomes [ 12 ]. Even after successful treatment, patients may have ongoing lung disease and a decreased life expectancy [ 13 , 14 , 15 ].

The drugs used to treat tuberculosis are well understood clinically, and susceptibility testing will indicate which treatment regimen is appropriate [ 11 , 12 ]. However, treatment effectiveness depends on patient adherence to a demanding and lengthy treatment regimen with associated side effects. In this context, a patient-focused approach which considers the individual’s specific circumstances is needed to ensure sufficient adherence and good outcomes from therapy. Interest in this field has been building steadily and is most suited to a qualitative investigational approach which allows deep exploration of motivations, reactions, goals, aspirations, and circumstances. However, studies more often consider the challenges faced by healthcare workers caring for TB patients [ 16 ], or the implementation of new management tools [ 17 , 18 ].

Previous studies have examined how patients manage their illness and the impact that TB has on their daily lives, their families, and the wider community [ 19 , 20 ], as well as the stigma associated with poverty and HIV and the effects of discrimination [ 21 ]. However, defining studies on the experiences of TB patients and their families are not available for all the BRICS countries, and comparison between studies with different methodologies and objectives is problematic. It is, therefore, unclear to what extent the experiences of TB patients are shared across countries.

We report the findings of a qualitative evaluation of TB patients’ experiences across the five BRICS countries. The study aimed to identify commonalities across the different country contexts, by examining the perspectives of TB patients throughout their full disease journey, including the emotional, psychosocial and practical challenges that patients and their families face. A greater understanding of these factors could inform care more focused on patients’ needs, with the aim of improving outcomes and directing the development of new tools to end TB.

Study design

This qualitative market research study was designed collaboratively by GSK and Adelphi Research and conducted between July 2020 and February 2021 across the five BRICS countries (Brazil, Russia, India, China, and South Africa). The study was non-interventional and without clinical endpoints. The aim was to achieve a better understanding of the TB market across the BRICS countries by identifying common challenges faced by TB patients and their families in their daily lives throughout their treatment journey.

The study conformed to ethical principles laid down in the Declaration of Helsinki, all national data protection laws and industry guidelines. Participants’ data was protected by compliance with General Data Protection Regulation [ 22 ]. All participating patients and household members provided written voluntary informed consent, and parents provided written consent for children under the age of consent. Consent was also provided for anonymized publication of the findings. For consent forms see supplementary materials, Additional file 1.

To investigate the experiences, meanings, and perspectives of TB patients, qualitative methodology was employed to identify themes within and across countries from in-depth interviews and self-recorded videos, supported by a self-completed health questionnaire.

Participants with experiences relevant to the study objectives were actively recruited from BRICS countries because they account for more TB cases than any other country in their respective WHO regions, and because of the different additional challenges confronting these countries such as the burden of TB-HIV co-infection in South Africa, the diversity of private sector care in India, and the burden of MDR-TB in India, China and Russia [ 1 , 2 , 23 ]. Remote data collection both preserved the privacy of participants and ensured the safety of moderators given the infectious nature of TB and the timing of the study during the COVID-19 pandemic.

Recruitment

Participants were recruited through independent healthcare fieldwork agencies in the different countries via referral from healthcare professionals and social or community workers, as well as using market research databases, posters and adverts in TB clinics, patient groups, and word of mouth referrals. Participants had the opportunity to discuss the study with recruiters before completing a screening guide to confirm patient eligibility (Additional file 2). Recruited participants received an honorarium at fair market value for their participation.

Recruitment continued until TB patients from 40 households, that is 8 per country, plus 1–5 members of their households had been sampled. The minimum target sample size was 80 participants. Previous studies have indicated that for this type of qualitative research as few as 6 interviews per setting are required to identify major themes [ 24 , 25 ], with saturation occurring within 12 interviews [ 26 ].

Participants

Eligible participants had a confirmed diagnosis of TB and were receiving treatment or had completed treatment within the previous 12 months. Close family and other household members were included where appropriate for support and additional information, except for China where the social stigma prevented discussion with individuals other than the patient. Participants were recruited from a range of socio-economic backgrounds, assessed based on income, education levels, and living standard. At least three participants from each country were to be female. The study sought to include a range of specific patient types, for example, persons living with HIV (PLWH), those with diabetes, smokers, those with a history of excessive alcohol consumption, and those with MDR-TB/relapsed TB. At least two patients per country were to be living in households which included a child diagnosed with TB or receiving preventive treatment. No participant was excluded because of lack of access to technology as the necessary equipment was loaned to participants where needed.

Data collection

The interview moderators, fluent in the local languages, were taken through a training process in each setting, detailing study objectives, inclusion criteria, and study methodology, followed by subsequent monitoring of the process and active feedback to ensure quality control. Data quality was assured by consistent and thorough briefing of the field workers, including regular follow up to ensure study procedures were followed. The discussion guide and videoing instructions were carefully designed to contain clear respondent instructions at each question.

Patients first completed a 5-min health questionnaire based on their physical health over the previous four weeks. Interviews with TB patients and household members were conducted remotely by a trained moderator in the form of either a 60-min video-streamed interview or a 60-min telephone interview. The questionnaire and interview guides are provided in the supplementary materials (Additional file 3). Participants also completed a 45-min follow up video task to create four short videos on a mobile phone in their own time to capture their personal experience, such as their living environment, changes in their living arrangements as a result of TB, the biggest challenges since the diagnosis, perception of the changes in their life from others around them, and their hopes and expectations for the future.

The interviews were transcribed verbatim from the original languages, that is: Brazil, Portuguese; Russia, Russian; India, Hindi and English; China, Mandarin; South Africa, English, Sesotho, isiZulu, Tswana, or Afrikaans with switching between languages as necessary. Following translation into English, the information was analysed manually using a thematic and comparative analysis approach to identify key themes both within countries and across all participants’ responses [ 27 , 28 ]. Analysts had no access to patient medical records and all patient identifying information was anonymized.

Interviews were coded thematically by three analysts, aiming to reach consensus through regular team meetings where the emerging findings were discussed. Additionally, non-verbal communication (including visual evidence of living conditions) present in the videos from the streamed interviews and the video tasks were shared with the full team at regular intervals and discussed/analysed using the thematic framework developed from the transcripts. Triangulation across the different data sources was done using cross-checking to assess convergence, complementarity and divergence at the individual participant level, between patients and their families, and at the country level between informants from the same country. The analysis was therefore grouped initially by country and then analysed for cross-cutting themes across all respondents. Quality control was achieved by continuous review by two senior analysts, one of whom was not involved in the initial analysis, plus a final check through all the analyses.

The sample consisted of 40 TB patients (8 from each country) plus 52 household members. Each patient was assigned an identifier to illustrate their country and number. Of the TB patients, 23 were men and 17 women, ranging between 13 and 60 years old. Fourteen were receiving first-line treatment, 10 second-line treatment, 2 patients had received multiple treatment lines, 11 had completed treatment, and 3 patients (all from Russia) were on a treatment break (Table 1 , Fig.  1 ). Risk factors for TB were reported in 23/40 patients, with some patients having multiple risk factors (Table 1 , Fig.  1 ). Most patients were of medium socio-economic status for their country (26/40), and no patients with high socio-economic status were recruited (Table 1 ). Except for India and South Africa, it was not possible to recruit at least two households with a child diagnosed with TB or receiving preventive treatment (Table 1 ).

Summary of patient characteristics. Note that patients may have had more than one risk factor/co-morbidity

Patient health status

The self-reported health questionnaire indicated that most respondents (25/40) found that the physical impact of TB limited their activity. A higher proportion of patients who were currently receiving treatment (69.6% [16/23]) reported a physical impact of TB compared with those that had completed treatment (57.1% [8/14]) or who were on a treatment break (33.3% [1/3]). Most patients whose physical activity was impacted by TB reported that this affected them all or most of the time (88.0% [22/25]) (Fig.  2 A). Most patients (38/40) reported that their daily living was impacted in at least two ways (Fig.  2 B). Seven patients, five of whom were receiving treatment and two who had completed first-line treatment, stated that they were impacted by all six areas assessed (Fig.  2 B). Looking at specific impacts, the most reported were that TB stopped patients doing things that they liked to do (35/40), and economic hardship (28/40) (Fig.  2 C). Overall, it was clear that TB had significantly impaired the health status of patients and had a negative impact on daily living.

Results of a self-reported health questionnaire. A The effect of TB on limiting daily activity due to patients’ physical health; B ) the impact of TB on daily living; and C ) the number of impacts on daily living experienced by patients

Patient journey

Pre-diagnosis.

The most common initial symptoms reported by patients were a long-lasting cough increasing in severity over time, fever, weight loss, and tiredness. Some patients experienced more severe symptoms such as haemoptysis, and pleural effusion. However, symptoms were often non-specific, and unless they were aware of a source of infection or had known risk factors (e.g. HIV), most patients did not consider TB as a potential cause. Notably, patients in South Africa were more likely to suspect TB because of a higher awareness in the community and the link with HIV. In India, recent typhoid infection was suspected as the cause of symptoms in some cases.

Patients tended to hope that the symptoms would resolve on their own using over-the-counter products and traditional medicine. Patients with addiction to alcohol did not always perceive the severity of their symptoms and were less willing to engage with healthcare providers. However, avoidance of healthcare providers was common across all settings, because of concerns for the associated costs.

“The symptoms were there for the last 2 ½ months but I did not know. He was coughing a lot, so I asked him to go to the doctor. He did not listen to me. He feared talking to the doctor.” Relative of TB patient, India (IN19). “One day, I started to have fever in the afternoon. After work, I went to receive infusion in a small local clinic. I remember my body temperature was 39.5 to 39.6 degrees Celsius. The doctor said my condition was very serious, so he prescribed 5 bottles of infusion to me, and I received all of them. But my fever persisted after such a lengthy infusion.” China (CN09).

The pathway for TB cases depended on symptom severity at presentation but navigating the healthcare system was tortuous for some patients. Patients first sought help using a familiar and accessible route (Fig.  3 ).

The TB patient pathway. *There were no deaths during the study

Across all countries, the TB diagnosis came as a shock to most patients – their initial thought was ‘Will I die?’. PLWH were less surprised as they were aware of the association with TB. Some patients in South Africa believed they had been vaccinated against TB as children and were therefore protected. Many patients questioned how they had caught TB and worried about the negative misconceptions associated with the disease, particularly in Russia and Brazil. Patients feared that they would be ostracized and shunned by their families and communities. Young people with TB feared for their future, for example their careers, education, and prospects of marriage. Further concerns expressed by patients included the potential disruption to their life, job security and providing for their dependents, especially in India. Overall, there was uncertainty among patients as to whether they could cope; some expressed the fear of unintentional disclosure of their TB diagnosis to others. Notably, across all countries, families were often fearful of the potential costs, with a lack of clarity regarding which elements of treatment would be covered by insurance (where available) or were refundable from the public health system.

“[I thought] it is some kind of prison disease, which occurs more and more often in people who have served a sentence somewhere. That is, more disadvantaged groups of the population. I always thought about it in this way until I met it myself.” Russia (RU10).

Following diagnosis, healthcare providers were quick to reassure patients that TB is treatable but that it will take time and that they must try not to infect others. In South Africa some patients reported being warned of drug resistance. However, beyond this, TB-focused education was limited, and patients often conducted their own research via the Internet and word of mouth, though patient-friendly resources were described as inadequate in some settings.

“[The nurse] said if you don’t take your meds, they send you to [a TB hospital] and then you will receive extreme treatment. They inject you with needles and stuff. That is if you don’t use this meds at home, they will send you there and stay for six months.” South Africa (SA05).

Treatment side effects, pill burden, lifestyle restrictions and the long-term commitment required were very challenging for patients (Fig.  4 ). Patients generally did not know the names of their medications, but described having to take many pills of different types several times a day. Patients reported intolerable side effects, including nausea and vomiting, and patients with MDR-TB faced painful daily injections. In Russia, and to a lesser extent in China, patients were admitted to hospital to increase adherence. In Russia, patients recounted being admitted to sanatoriums for the treatment of TB.

“I take many anti-TB pills every day, covering 4–5 classes, about 20 tablets in total. Sometimes, it’s difficult for me to take medication, as I was quite reluctant to take it initially, but I had no choice, but to take it as a treatment.” China (CN11).

Factors identified by patients as affecting adherence to TB therapy

Monitoring and adherence

Across countries and socioeconomic bands, patients perceived minimal therapy monitoring by healthcare providers, with little evidence of DOT. It is possible that this was because of interruption to normal healthcare services because of the COVID-19 pandemic (see below). Most patients visited healthcare settings frequently to pick up their medications. Less frequently, their weight was measured during clinic visits, sputum tests were conducted, and some patients were informed when they were no longer infectious and could return to work/education. Family played a key role in monitoring during treatment, encouraging patients to continue with their treatment, sharing regular reminders, and helping to pick up medication from health centres. Motivation to comply was prompted by the desire to get back to normal family life and work, the fear of death, potential drug resistance, and hospitalization. Although patients would briefly lapse without serious consequences, they were usually encouraged to continue treatment by family and healthcare providers.

“Sometimes [redacted] forgets to take the medication, and I argue with him because if one of us forgets the treatment and the other one doesn’t then it won’t work, if we don’t take it together, it won’t work.” Brazil (BR04).

Once treatment was initiated, health improvements were quickly apparent to most patients, with resolution of fever and abatement in cough. Although this increased patients’ optimism and secured a return to some of their previous activities, it could also lead patients to believe that they had recovered, undermining adherence to therapy. Adherence was also jeopardized where there were high barriers to accessing treatment, a poor understanding of drug resistance, and when patients were alcohol dependent (Fig.  4 ). Patients who did adhere to treatment were often well supported by family and well informed of the consequences of non-adherence. Conversely, those who did not adhere to treatment were often unaware of the consequences.

“By December I was already feeling like I’m already cured, I nearly decided not to continue with the treatment.” South Africa (SA01). “Actually, they didn’t tell me about the details then. It was very important to emphasize it to me, but the physician didn’t do it. If he did, it would draw my attention and it won’t lead to drug resistance, as I often missed the dose I was supposed to take.” China (CN06). “I live in a little town which is quite far from the city. I can either go by bus which takes at least an hour and a half, or I can get to the nearest bullet train, but there aren’t many trains available and they are expensive.” China (CN08).

Completion of treatment

Eleven patients had completed treatment, 4 from South Africa, 4 from India, 2 from Brazil, and 1 from China. All had recovered, 10 following first-line treatment and 1 following second-line treatment (India). Some respondents said that their time in isolation was a time of reflection where their lives had been ‘put on pause’ making them ‘appreciate the little things in life’ they had really missed. A few patients said that their experience with TB has driven them to want to increase awareness, and remove stigma around the disease e.g., patients in Brazil and China set up informal support networks with fellow patients, particularly where patients met during hospital stays. Most patients expressed relief that they were cured, and that treatment was over, and were generally hopeful for their future.

"My TB is cured, and I want to start again with my studies. I was preparing for a railway job but I had to give that up because of TB. Now I will start my studies again and apply for a government job." India (IN04). "Thanks to this [TB] I got rid of bad habits, I do not drink alcohol now and smoke less… And I found a job, and I earn some money at the moment, during the first period my brother supported me fully, thanks to him, and my mother helped what she could.” Russia (RU05). "After these three months since I have recovered, this is what it has brought me, the willingness to fight, to battle, also to take even more care of my health, not just mine but also of people around me, and take this story, my testament, my lived experience with TB… So it’s a goal in my life, to spread information among all those who are close to me." Relative of TB patient (BR01).

Access to services

Before TB was diagnosed, in some cases patients consulted healthcare providers in the private sector, for example, the local family doctor, traditional medicine providers, or pharmacies. Following diagnosis, more affluent patients claimed on insurance or paid for private sector treatment due to poor perceptions of the public sector, and some sought support in the private sector for a ‘second opinion’ or for problems which they felt were not being addressed in the public sector. However, the majority of patients (36/40) obtained their TB care through the public sector; three patients used the private sector with one accessing both public and private sector healthcare. Treatment was provided for free through the national programs, with relatively good access in most settings, though travel distance and wait times were a barrier to access. There were reports of drug stock outs and out of pocket expenses for additional diagnostic tests or prescriptions, including having to pay for MDR-TB treatment in some settings (China). A minority of patients reported being turned away from the public sector for not having the correct paperwork or not being able to book an appointment. The public sector had a poor reputation for long queues and poor service and most patients aspired to be able to afford private treatment where services were described as being better.

“In public [sector healthcare] those nurses don’t care, I remember when I accompanied him, I was told I was not allowed to get inside, so he went in on his own. You go in pick up whatever you need and get out because those people don’t have time for anything.” Relative of TB patient, South Africa (SA01). “In the Government hospital, the doctors do not listen to us. They come when they wish and give medicines. As it is, the doctors do not listen to poor people. I had to buy some medicines from outside.” Relative of TB patient, India (IN17). “Obtaining the medication – because the drugs can only be obtained in the hospital, you can’t buy them in retail pharmacies. If I run out of my medication, I wouldn’t be able to buy it from the retail pharmacy, I would have to go the hospital, which is inconvenient.” China (CN08).

The use of sanatoriums in Russia was unique. Following diagnosis, patients were sent to a dedicated facility or a TB unit within a hospital where they remained for at least 3–4 months, though confinement could last for up to a year. They were only allowed to leave with permission, for example, at weekends or holidays. Although patients generally accepted that it was for the ‘greater good’ it was frightening at first because some other patients on the ward had very severe disease. However, some patients expressed surprise that other patients were ‘normal’, because they believed the disease to be often associated with homelessness and prisons.

“They told me I had a resistant form of TB and that the treatment is very, very long lasting. At first, they said I would have to be hospitalized three to four months and that then I would be able to go home but when I got to the hospital, the ‘girls’ told me that three to four months is optimistic… In short, eight months. Eight in the hospital and a year after the hospital. That was a shock.” Russia (RU12). “In my room there were all young women and all were so great. All of them were socially adapted: an accountant, a paediatrician student. So, let’s say it was good company.” Russia (RU01).

Thematic analysis

Five major themes were identified as common across all the countries studied (Fig.  5 ).

Thematic areas identified as common across five countries describing the challenges faced by TB patients

Economic hardship

Loss of earnings has the greatest economic impact for TB patients. Most patients stopped work because they felt too unwell to continue or were embarrassed by the symptoms, such as the persistent cough and severe weight loss. Some patients also felt the need to stay away from work to limit transmission to others or were ‘asked to leave’ by their employers as they were not covered by contracts. Many had no entitlement to sick pay. In some cases, patients were concerned that their financial situation could get worse as their diagnosis may mean prospective employers may be reluctant to take them on.

“The main problem is money. There is no problem greater than financial problems.” India (IN01). “I had to keep away from work because there was a lot of dust involved.” Brazil (BR15). “I cannot officially get a job, and I cannot unofficially either. But, what? Am I going to work as a loader? I cannot. This has seriously affected my finances… And who would hire if information comes out that there was TB? You will not get a job. I received a disability [payment].” Russia (RU05).

Even in regions where TB treatment was publicly funded, associated costs such as tests, hospitalization, prescriptions, travel, special food/supplements to manage weight loss, and medications to manage adverse effects were often borne by patients. The financial impact of TB meant that most patients had to rely on family or sometimes charities for support or take out loans. Time off for appointments still impacted earnings even after patients had returned to work.

“I also buy medications at my own expense [for gastric side effects] i.e. for TB, everything is free of charge due to the medical insurance policy, everything is fine, but if there is something secondary or something else not related to the diagnosis, then that is at your own expense.” Russia (RU07). “We are not educated people. I just wanted my child to recover. We are poor people; we could not work during lockdown. We had to borrow money from many people and requested help from doctors too. I thought my child would recover, but he did not. We were very stressed out.” Relative of TB patient, India (IN21). “To avoid delaying treatment, the doctor told me to take these four drugs upon diagnosis, and urged me to buy them elsewhere, as they were unavailable in the hospital. My wife found they were unavailable in many pharmacies either. Finally, she found them in several pharmacies, from where we bought them in early stage.” China (CN09).

Stigma associated with TB

Across all countries stigma was associated with TB, though it manifested in different ways. In China, TB was often kept a secret, even from family, whereas in South Africa, there was greater openness. In Brazil, though patients were open with family, there was reluctance to acknowledge their diagnosis with their community as TB is associated with wider social issues such as poverty, incarceration and ‘immoral lifestyles’. In India, TB patients felt discriminated against for other reasons, such as poverty, as well as TB. Stigma in Russia was related to the personal circumstances of the patient.

Young patients faced bullying at school/college and being dropped by friendship groups. Adults were ostracized by friends and relatives afraid of contracting TB, and relationships with friends and family suffered, leading to loneliness and depression. Respondents described instances when they were not invited to family events even after they had completed treatment and were cured. In some cases, TB appeared to ‘run in families’ meaning the stigma was intergenerational. Importantly, a family with TB was often considered a ‘low status’ family and this was compounded by the financial difficulties that accompany TB.

“A lot of my friends kept away from me because of this, because that’s what people know, that it’s contagious, but they don’t understand that the person on the other side is suffering as well, and we don’t only suffer a little bit, at least myself, it’s a very painful process, very painful, very complicated.” Relative of TB patient, Brazil (BR01). “The community was no longer as close to us because we are staying with a person that has TB – people at the queue at shops would turn around and come back when we have left.” Relative of TB patient, South Africa (SA14). “When a person has TB he becomes very annoyed as he has to go through a lot of things, plus there also comes a phase were people start avoiding you, they feel that if we come in contact with this person even we might acquire it.” India (IN01). “A person who has TB is not somebody who is well-regarded.” Brazil (BR04).

HIV co-infection played a major role in the TB experience, particularly in South Africa. Awareness of TB was higher among PLWH given their greater risk and regular contact with healthcare services. Also, the path to diagnosis was shorter given their engagement with HIV services with rapid referral reflecting the associated co-infection risks. In many cases, the HIV and TB clinics were co-located improving patient access. However, PLWH were highly aware of the stigma that TB carries with fear around the community reaction during the early stages of their journey.

"Now I’m scared I’m HIV positive, I have TB and now there’s Corona [COVID-19], what’s going to happen when I have all three of them?" South Africa (SA18). “So people were really scared, I think they are now more afraid of TB than HIV. I told my neighbour that I was diagnosed with TB and luckily she doesn’t talk much but still I was aware of their behaviour when they came by to do my laundry they would wait outside to hand it over to them and when they are done they would leave it by the door." South Africa (SA10).

Disruption to family life

A diagnosis of TB affects everyone in the household and the wider family. Cleaning and disinfecting routines have to be established and maintained, and there was a general awareness that separate cutlery must be used, living spaces needed good ventilation, and clothes and bedding should be washed more frequently. Sleeping arrangements to isolate TB patients were particularly problematic in India and South Africa where large families live together, and parental co-sleeping with children was no longer possible where this was practiced. In some cases, children were looked after in the homes of extended family members, away from parents with TB. Married patients feared abandonment or divorce and respondents felt ‘lucky’ that their partners had stayed with them despite their TB status. The reduced family contact, demands of treatment and financial hardship often strained family relationships.

“Life at home isn’t the same because I had to begin separating my cutlery and a glass – my clothes had to be washed separately, we have to clean down the house and open the windows to let the air circulate.” Brazil (BR15). “I’m worried I may infect my parents. So I’ve had to reduce my interactions with them, the time spent with them, the number of occasions I’m with them. And as they get older, they become confused and they don’t understand why I stay away.” China (CN08). “Our house always used to be full at weekends, friends would come around to watch films, sometimes we would make lunch, get pizza and sit and watch films, and then suddenly the house was empty.” Relative of TB patient, Brazil (BR01).

Mixed effects of COVID-19

Some TB patients observed that the COVID-19 pandemic normalized the idea of infection prevention, with mask wearing becoming common. Also, TB patients were able to hide their diagnosis more easily with social distancing measures. There was also less fear that they could infect the wider community. However, access to healthcare and medication was compromised with restrictions to movement and hospitals not accepting admissions for other conditions. Patients were fearful of ‘catching’ COVID-19 given their impaired respiratory health and existing co-morbidities, such as HIV and diabetes. Some respondents who were coming to the end of their isolation and anticipating greater freedoms and a return to a more normal life then faced COVID-19 restrictions.

“During the pandemic I was unable to go to the hospital for my regular follow-ups and prescription renewal, and so because of that my condition worsened, and I eventually ended up infecting my family.” CN08.

Assuming that efficacious treatment is provided, TB is curable. However, outcomes are often sub-optimal. This study aimed to explore common themes in the experiences of TB patients and their families in the five BRICS countries from diagnosis to completion of treatment. Using consistent methodology, economic hardship, stigma, TB-HIV co-infection, disruption to family life, and the mixed effects of COVID-19 were identified as themes encompassing the challenges facing TB patients across the five BRICS countries (Fig.  5 ). These factors, therefore, appear to be independent of the country setting. Further research should investigate the degree to which these factors and are potentially mutable by targeting systemic changes in healthcare and social provision and providing attention to patients’ individual needs.

Economic hardship was reported across all countries. TB is associated with economic vulnerability but can also drive families into poverty through loss of income, the costs of transportation and food supplements, and associated medical expenses [ 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 ]. Programs providing social protection to TB patients have been linked to improved outcomes and the increased uptake of preventive therapy but must be easily accessible [ 29 , 37 , 38 ]. Improvement of TB services can also reduce the number of families facing financial hardship [ 39 ]. Even though most healthcare systems in our study provided TB drugs free of charge, to be effective, treatment should encompass the wider economic impacts that patients experience. Despite various approaches, patients from all of the countries surveyed found themselves struggling financially and a more holistic approach to patient support is needed.

Stigma attached to TB is culturally distinct, but stems from a lack of awareness of TB and the persistence of stereotypes [ 40 , 41 ]. For example, in Russia, an association with prisons and poverty has persisted, despite TB affecting all sectors of society [ 42 ]. Stigma was most acutely felt in China, and a recent study described psychological distress in nearly two-thirds of TB patients, associated with a high experienced stigma [ 43 ]. In our study, some patients did not even disclose their diagnosis to close family. In newly diagnosed Chinese TB patients, non-disclosure of their TB status magnified patient-perceived stigma and was associated with depression – a risk factor for non-adherence [ 44 , 45 ]. Social support and doctor–patient communication appeared key factors for reducing TB-related stigma in China [ 46 ]. Also, educational approaches to raise awareness of TB diagnosis and treatment among the public are needed, particularly focused on those with low educational levels and more rural communities [ 40 , 47 , 48 ].

The association between TB and HIV is well documented. However, the impact on patients is less well understood. In this study, PLWH were more aware of TB and were more likely to seek care early and be diagnosed quickly. This is in contrast to a study in Thailand where PLWH had low TB awareness and attributed their early symptoms to AIDS, resulting in delayed TB diagnosis [ 49 ]. This emphasizes the importance of raising TB awareness in PLWH. In South Africa, TB and HIV services are often co-located and integrated [ 50 ]. However, a detailed analysis in South Africa of the challenges faced by PLWH who had MDR-TB highlighted similar issues to those described here for all TB patients, such as fear, stigma, dissociation from family and social networks, poor provider support, drug adverse events, and financial insecurity [ 51 ]. Also, patients tended to prioritize adherence to anti-retroviral therapy versus TB therapy because it was less challenging in terms of pill burden and adverse effects [ 52 ]. Until less demanding treatment regimens are available, targeted support to address the challenges of adherence in patients co-infected with TB-HIV is necessary.

The respondents in this study described a severely disrupted home life following a TB diagnosis. Patients were isolated and often infirm, and the economic and care responsibilities for family members were considerable. Families also suffered socially, being isolated or shunned by friends and the wider family. In many cases, it was family members who ensured adherence to medication, and social and family support for patients has been previously shown as a key factor in therapy adherence [ 41 , 53 , 54 ]. Despite this, the impact of the TB diagnosis on the family and how family members can best be supported has been rarely investigated [ 47 ], and we identify this as an important area for further research.

The COVID-19 epidemic has disrupted healthcare access globally [ 55 ]. In our study, TB patients reported drug shortages and restrictions to services during the period. TB patients also expressed concern regarding the consequences of contracting COVID-19. Similarly, a recent study in Brazil reported that TB patients were fearful of attending medical appointments [ 56 ]. TB patients do appear to be at greater risk of death or poor outcome with COVID-19 [ 57 ], and should therefore socially isolate or ‘shield’ [ 58 ]. TB patients did feel less stigmatized as social distancing and infection control measures were deployed for COVID-19. However, the interruption of treatment, with the risk of therapy failure, selection of MDR-TB, and increased transmissibility is a major threat to TB patients and their close contacts [ 59 ].

This study has several limitations. Although participants were identified through a variety of channels and a range of socioeconomic groups were sampled, this was not a randomized sample and we acknowledge that both marginalized and privileged groups may not engage in this kind of research. Also, there were no data on whether susceptibility testing was conducted following the TB diagnosis, so the appropriateness of therapy could not be assessed. Neither did we examine the differences between patients’ experiences of drug-susceptible versus MDR-TB; patients were not consistently aware of the difference and most patients were receiving or had recently completed first-line therapy. The patient pathway was not integrated into the thematic analysis but analysed separately in terms of the systemic challenges that patients face. This was because the complexity of the pathway did not map onto the themes in a meaningful way. For example, patients experienced economic hardship, stigma, and disruption to family life at most stages in the patient pathway, whereas TB-HIV co-infection had an important effect on the speed of diagnosis. Thus, patient pathway was examined systematically and separately to the thematic analysis which focused on the emotional, socio-economic and practical impacts of TB on patients’ daily lives. The analysis methods sought to remain impartial with repeated reviews by multiple analysts to reach consensus. However, the analysts were all based in the UK and we recognize that the cultural subtleties of some of the patients’ experiences may not have been fully appreciated.

In our study, TB patients’ perceptions and needs were expressed in their own words, from within their home environment, in confidence, to interviewers who were not involved in their healthcare. Most had struggled to adjust to their diagnosis, had poor access to information, lacked support from healthcare workers, were under significant financial pressure, and were highly conscious of stigma and the burden TB placed on their families.

Our findings highlight that much work still needs to be done before the goal of ending TB can be achieved. Structural changes require simplification of the TB patient pathway, reliable access to services, and the alleviation of financial pressures. Health education for patients, their families, healthcare providers and the public to increase awareness of TB symptoms and diagnosis, to encourage adherence, and to reduce stigma around the disease is needed. Importantly, TB patients do better with strong family and social networks to sustain them, and a greater understanding of how these can be better supported at the level of the individual patient throughout the TB treatment journey requires further investigation.

Despite the different cultural, political, and healthcare settings across the BRICS countries, TB patients faced very similar challenges. This commonality would not necessarily have been expected. It suggests that these factors are not only a product of the healthcare provision in the countries or the social, economic, and cultural pressures that patients face, but reflect an overarching insufficiency in the treatment of TB. The efficient delivery of comprehensive individualized care and support would certainly mitigate the negative impacts of TB on patients. However, these issues will likely not be fully resolved until treatment options are available that rapidly cure TB and prevent onward transmission.

Availability of data and materials

All relevant data are included in this publication. Recorded interviews will not be made available in order to maintain patient confidentiality. However, anonymised transcripts are available on reasonable request to the authors for ten years following study completion. For data requests please contact the corresponding author at [email protected].

Abbreviations

Coronavirus disease of 2019 (severe acute respiratory syndrome coronavirus 2)

Human immunodeficiency virus

Multidrug-resistant tuberculosis

People living with HIV

• Tuberculosis

World Health Organization. Global tuberculosis report 2021. 2021. https://www.who.int/publications/i/item/9789240037021 . Accessed 1 Nov 2021.

Creswell J, Sahu S, Sachdeva KS, Ditiu L, Barreira D, Mariandyshev A, Mingting C, Pillay Y. Tuberculosis in BRICS: challenges and opportunities for leadership within the post-2015 agenda. Bull World Health Organ. 2014;92(6):459–60.

Article   PubMed   PubMed Central   Google Scholar  

World Health Organization. Global tuberculosis report 2020. 2020. https://www.who.int/publications/i/item/9789240013131 . Accessed 1 Nov 2021.

World Health Organization. The End TB Strategy: Global strategy and targets for tuberculosis prevention, care and control after 2015. 2014. https://www.who.int/tb/strategy/End_TB_Strategy.pdf . Accessed 4 July 2021.

Floyd K, Glaziou P, Houben R, Sumner T, White RG, Raviglione M. Global tuberculosis targets and milestones set for 2016–2035: definition and rationale. Int J Tuberc Lung Dis. 2018;22(7):723–30.

Article   CAS   PubMed   PubMed Central   Google Scholar  

United Nations General Assembly. A/RES/73/3. Political declaration of the high-level meeting of the General Assembly on the fight against tuberculosis. 2018. https://www.un.org/en/ga/search/view_doc.asp?symbol=A/RES/73/3 . Accessed 4 July 2021.

World Health Organization. WHO consolidated guidelines on tuberculosis. Module 1: prevention – tuberculosis preventive treatment. 2020. https://www.who.int/publications/i/item/who-consolidated-guidelines-on-tuberculosis-module-1-prevention-tuberculosis-preventive-treatment . Accessed 4 July 2020.

Shete PB, Reid M, Goosby E. Message to world leaders: we cannot end tuberculosis without addressing the social and economic burden of the disease. Lancet Glob Health. 2018;6(12):e1272–3.

Article   PubMed   Google Scholar  

Hoos A, Anderson J, Boutin M, Dewulf L, Geissler J, Johnston G, Joos A, Metcalf M, Regnante J, Sargeant I, et al. Partnering with patients in the development and lifecycle of medicines: A call for action. Ther Innov Regul Sci. 2015;49(6):929–39.

Reichler MR, Khan A, Yuan Y, Chen B, McAuley J, Mangura B, Sterling TR. Tuberculosis epidemiologic studies consortium task order team: Duration of exposure among close contacts of patients with infectious tuberculosis and risk of latent tuberculosis infection. Clin Infect Dis. 2020;71(7):1627–34.

World Health Organization. Guidelines for treatment of drug-susceptible tuberculosis and patient care. 2017. https://apps.who.int/iris/bitstream/handle/10665/255052/9789241550000-eng.pdf . Accessed 4 July 2021.

World Health Organization. WHO consolidated guidelines on tuberculosis. Module 4: treatment - drug-resistant tuberculosis treatment. 2020. https://www.who.int/publications/i/item/9789240007048 . Accessed 4 July 2021.

Hoger S, Lykens K, Beavers SF, Katz D, Miller TL. Longevity loss among cured tuberculosis patients and the potential value of prevention. Int J Tuberc Lung Dis. 2014;18(11):1347–52.

Article   CAS   PubMed   Google Scholar  

Allwood BW, Byrne A, Meghji J, Rachow A, van der Zalm MM, Schoch OD. Post-tuberculosis lung disease: Clinical review of an under-recognised global challenge. Respiration. 2021;100(8):751–63.

Mkoko P, Naidoo S, Mbanga LC, Nomvete F, Muloiwa R, Dlamini S. Chronic lung disease and a history of tuberculosis (post-tuberculosis lung disease): Clinical features and in-hospital outcomes in a resource-limited setting with a high HIV burden. S Afr Med J. 2019;109(3):169–73.

Matakanye H, Ramathuba DU, Tugli AK. Caring for tuberculosis patients: Understanding the plight of nurses at a regional hospital in Limpopo Province, South Africa. Int J Environ Res Public Health. 2019;16(24):4977.

Article   PubMed Central   Google Scholar  

Thomas BE, Kumar JV, Periyasamy M, Khandewale AS, Hephzibah Mercy J, Raj EM, Kokila S, Walgude AS, Gaurkhede GR, Kumbhar JD, et al. Acceptability of the medication event reminder monitor for promoting adherence to multidrug-resistant tuberculosis therapy in two Indian cities: Qualitative study of patients and health care providers. J Med Internet Res. 2021;23(6): e23294.

Milligan H, Iribarren SJ, Chirico C, Telles H, Schnall R. Insights from participant engagement with the tuberculosis treatment support tools intervention: Thematic analysis of interactive messages to guide refinement to better meet end user needs. Int J Med Inform. 2021;149: 104421.

Dias AA, de Oliveira DM, Turato ER, de Figueiredo RM. Life experiences of patients who have completed tuberculosis treatment: a qualitative investigation in southeast Brazil. BMC Public Health. 2013;13:595.

Bhattacharya Chakravarty A, Rangan S, Dholakia Y, Rai S, Kamble S, Raste T, Shah S, Shah S, Mistry N. Such a long journey: What health seeking pathways of patients with drug resistant tuberculosis in Mumbai tell us. PLoS ONE. 2019;14(1): e0209924.

Courtwright A, Turner AN. Tuberculosis and stigmatization: pathways and interventions. Public Health Rep. 2010;125(Suppl 4):34–42.

The European Parliament and the Council of the European Union: Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data, and repealing Directive 95/46/EC (General Data Protection Regulation). Official Journal of the European Union. 2016;L119:1-88.

An Q, Song W, Liu J, Tao N, Liu Y, Zhang Q, Xu T, Li S, Liu S, Li Y, et al. Primary drug-resistance pattern and trend in elderly tuberculosis patients in Shandong, China, from 2004 to 2019. Infect Drug Resist. 2020;13:4133–45.

Isman E, Ekeus C, Berggren V. Perceptions and experiences of female genital mutilation after immigration to Sweden: an explorative study. Sex Reprod Healthc. 2013;4(3):93–8.

Isman E, Mahmoud Warsame A, Johansson A, Fried S, Berggren V. Midwives’ experiences in providing care and counselling to women with female genital mutilation (FGM) related problems. Obstet Gynecol Int. 2013;2013:785148.

Guest G, Bunce A, Johnson L. How many interviews are enough?: An experiment with data saturation and variability. Field Methods. 2006;18:59–82.

Article   Google Scholar  

Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77–101.

Green J, Thorogood N. Qualitative methods for health research. 2nd ed. London: Sage; 2009.

Google Scholar  

Aragao FBA, Arcencio RA, Fuentealba-Torres M, Carneiro TSG, Souza LLL, Alves YM, Fiorati RC. Impact of social protection programs on adults diagnosed with tuberculosis: systematic review. Rev Bras Enferm. 2021;74(3): e20190906.

Sinha P, Carwile M, Bhargava A, Cintron C, Acuna-Villaorduna C, Lakshminarayan S, Liu AF, Kulatilaka N, Locks L, Hochberg NS. How much do Indians pay for tuberculosis treatment? A cost analysis. Public Health Action. 2020;10(3):110–7.

Xu CH, Jeyashree K, Shewade HD, Xia YY, Wang LX, Liu Y, Zhang H, Wang L. Inequity in catastrophic costs among tuberculosis-affected households in China. Infect Dis Poverty. 2019;8(1):46.

Stracker N, Hanrahan C, Mmolawa L, Nonyane B, Tampi R, Tucker A, West N, Lebina L, Martinson N, Dowdy D. Risk factors for catastrophic costs associated with tuberculosis in rural South Africa. Int J Tuberc Lung Dis. 2019;23(6):756–63.

Yang T, Chen T, Che Y, Chen Q, Bo D. Factors associated with catastrophic total costs due to tuberculosis under a designated hospital service model: a cross-sectional study in China. BMC Public Health. 2020;20(1):1009.

Lu L, Jiang Q, Hong J, Jin X, Gao Q, Bang H, DeRiemer K, Yang C. Catastrophic costs of tuberculosis care in a population with internal migrants in China. BMC Health Serv Res. 2020;20(1):832.

Moreira A, Kritski AL, Carvalho ACC. Social determinants of health and catastrophic costs associated with the diagnosis and treatment of tuberculosis. J Bras Pneumol. 2020;46(5):e20200015.

Hutchison C, Khan MS, Yoong J, Lin X, Coker RJ. Financial barriers and coping strategies: a qualitative study of accessing multidrug-resistant tuberculosis and tuberculosis care in Yunnan, China. BMC Public Health. 2017;17(1):221.

Patel BH, Jeyashree K, Chinnakali P, Vijayageetha M, Mehta KG, Modi B, Chavda PD, Dave PV, Zala CC, Shewade HD, et al. Cash transfer scheme for people with tuberculosis treated by the National TB Programme in Western India: a mixed methods study. BMJ Open. 2019;9(12):e033158.

Rudgard WE, Evans CA, Sweeney S, Wingfield T, Lonnroth K, Barreira D, Boccia D. Comparison of two cash transfer strategies to prevent catastrophic costs for poor tuberculosis-affected households in low- and middle-income countries: An economic modelling study. PLoS Med. 2017;14(11):e1002418.

Verguet S, Riumallo-Herl C, Gomez GB, Menzies NA, Houben R, Sumner T, Lalli M, White RG, Salomon JA, Cohen T, et al. Catastrophic costs potentially averted by tuberculosis control in India and South Africa: a modelling study. Lancet Glob Health. 2017;5(11):e1123–32.

Lu SH, Tian BC, Kang XP, Zhang W, Meng XP, Zhang JB, Lo SK. Public awareness of tuberculosis in China: a national survey of 69 253 subjects. Int J Tuberc Lung Dis. 2009;13(12):1493–9.

PubMed   Google Scholar  

Deshmukh RD, Dhande DJ, Sachdeva KS, Sreenivas AN, Kumar AMV, Parmar M. Social support a key factor for adherence to multidrug-resistant tuberculosis treatment. Indian J Tuberc. 2018;65(1):41–7.

Zvonareva O, van Bergen W, Kabanets N, Alliluyev A, Filinyuk O. Experiencing syndemic: Disentangling the biosocial complexity of tuberculosis through qualitative research. J Biosoc Sci. 2019;51(3):403–17.

Chen X, Wu R, Xu J, Wang J, Gao M, Chen Y, Pan Y, Ji H, Duan Y, Sun M, et al. Prevalence and associated factors of psychological distress in tuberculosis patients in Northeast China: a cross-sectional study. BMC Infect Dis. 2021;21(1):563.

Lee LY, Tung HH, Chen SC, Fu CH. Perceived stigma and depression in initially diagnosed pulmonary tuberculosis patients. J Clin Nurs. 2017;26(23–24):4813–21.

Qiu L, Tong Y, Lu Z, Gong Y, Yin X. Depressive symptoms mediate the associations of stigma with medication adherence and quality of life in tuberculosis patients in China. Am J Trop Med Hyg. 2019;100(1):31–6.

Chen X, Du L, Wu R, Xu J, Ji H, Zhang Y, Zhu X, Zhou L. Tuberculosis-related stigma and its determinants in Dalian, Northeast China: a cross-sectional study. BMC Public Health. 2021;21(1):6.

Sathar F, Velen K, Peterson M, Charalambous S, Chetty-Makkan CM. “Knock”: a qualitative study exploring the experience of household contacts on home visits and their attitude towards people living with TB in South Africa. BMC Public Health. 2020;20(1):1047.

Rajalakshmi M, Kalaiselvan G, Sudhakar R, Dhikale PT. An exploratory mixed method study on the follow up status and quality of life among recurrent tuberculosis patients in South India. Indian J Tuberc. 2020;67(4):515–22.

Ngamvithayapong J, Winkvist A, Diwan V. High AIDS awareness may cause tuberculosis patient delay: results from an HIV epidemic area. Thailand AIDS. 2000;14(10):1413–9.

Lince-Deroche N, Leuner R, Kgowedi S, Moolla A, Madlala S, Manganye P, Xhosa B, Govathson C, White Ndwanya T, Long L. Voices from the front lines: A qualitative study of integration of HIV, tuberculosis, and primary healthcare services in Johannesburg, South Africa. PLoS ONE. 2020;15(10):e0230849.

Daftary A, Mondal S, Zelnick J, Friedland G, Seepamore B, Boodhram R, Amico KR, Padayatchi N, O’Donnell MR. Dynamic needs and challenges of people with drug-resistant tuberculosis and HIV in South Africa: a qualitative study. Lancet Glob Health. 2021;9(4):e479–88.

Daftary A, Padayatchi N, O’Donnell M. Preferential adherence to antiretroviral therapy over tuberculosis treatment: a qualitative study of drug-resistant TB/HIV co-infected patients in South Africa. Glob Public Health. 2014;9(9):1107–16.

Daniels J, Medina-Marino A, Glockner K, Grew E, Ngcelwane N, Kipp A. Masculinity, resources, and retention in care: South African men’s behaviors and experiences while engaged in TB care and treatment. Soc Sci Med. 2021;270: 113639.

da Silva RD, de Luna FDT, de Araujo AJ, Camelo ELS, Bertolozzi MR, Hino P, Lacerda SNB, Fook SML, de Figueiredo T. Patients’ perception regarding the influence of individual and social vulnerabilities on the adherence to tuberculosis treatment: a qualitative study. BMC Public Health. 2017;17(1):725.

Migliori GB, Thong PM, Akkerman O, Alffenaar JW, Alvarez-Navascues F, Assao-Neino MM, Bernard PV, Biala JS, Blanc FX, Bogorodskaya EM, et al. Worldwide effects of coronavirus disease pandemic on tuberculosis services, January-April 2020. Emerg Infect Dis. 2020;26(11):2709–12.

Santos FLD, Souza LLL, Bruce ATI, Crispim JA, Arroyo LH, Ramos ACV, Berra TZ, Alves YM, Scholze AR, Costa F, et al. Patients’ perceptions regarding multidrug-resistant tuberculosis and barriers to seeking care in a priority city in Brazil during COVID-19 pandemic: A qualitative study. PLoS ONE. 2021;16(4):e0249822.

Sy KTL, Haw NJL, Uy J. Previous and active tuberculosis increases risk of death and prolongs recovery in patients with COVID-19. Infect Dis (Lond). 2020;52(12):902–7.

Maciel ELN, Goncalves Junior E, Dalcolmo MMP. Tuberculosis and coronavirus: what do we know? Epidemiol Serv Saude. 2020;29(2):e2020128.

Singh A, Prasad R, Gupta A, Das K, Gupta N. Severe acute respiratory syndrome coronavirus-2 and pulmonary tuberculosis: convergence can be fatal. Monaldi Arch Chest Dis. 2020;90(3):441–50.

European Pharmaceutical Market Research Association. Code of Conduct 2020. 2020. https://www.ephmra.org/media/4857/ephmra-2020-code-of-conduct-final.pdf . Accessed 8 Feb 2022.

International Chamber of Commerce, European Society for Opinion and Marketing Research. ICC/ESOMAR International Code on Market, Opinion and Social Research and Data Analytics. 2016. https://esomar.org/code-and-guidelines/icc-esomar-code . Accessed 8 February 2022.

British Healthcare Business Intelligence Association. Legal and Ethical Guidelines for Healthcare Market Research: Your essential guide. 2021. https://www.bhbia.org.uk/guidelines-and-legislation/legal-and-ethical-guidelines . Accessed 8 Feb 2022.

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Acknowledgements

Naomi Richardson of Magenta Communications Ltd. in collaboration with Juliet Addo developed the first draft of this article from a research report, provided editorial and graphic services and was funded by GSK. Elizabeth Kehler, Francesca Trewartha and Thea Westwater Smith of Adelphi were co-authors of the original report and co-analysts. Carly Davies, Vera Gielen and Myriam Drysdale from GSK reviewed and provided comments on the screening and interview guides.

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J.A. made substantial contributions to the conception and design of the work, interpretation of the data and drafting of the manuscript. C.L., M.M., M.S., D.B-A., G.C.K.W.K. and D.P. made substantial contributions to the conception and design of the work and interpretation of the data and critically revised the manuscript for intellectual content. G.T. made significant contributions to the design of the work, the acquisition of data, analysis and interpretation of data for the work and critically revised the manuscript for intellectual content. All authors read and approved the final manuscript.

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Addo, J., Pearce, D., Metcalf, M. et al. Living with tuberculosis: a qualitative study of patients’ experiences with disease and treatment. BMC Public Health 22 , 1717 (2022). https://doi.org/10.1186/s12889-022-14115-7

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Intestinal tuberculosis is a chronic and specific infection caused by Mycobacterium tuberculosis invading the intestine. Due to the nonspecific clinical presentation, it is stressed that intestinal perforation complicates umbilical intestinal fistula and bladder ileal fistula is very rare and extremely difficult to be diagnosed. It is significant to identify the disease and take urgent intervene in the early stage.

Case presentation

An 18-month-old boy patient presented with abdominal pain. Abdominal CT suggested abscess formation in the right lower abdomen and pelvis. The patient underwent resection of necrotic and stenotic intestinal segments with the creation of an ileostomy, cystostomy and vesicoureteral fistula repair for the presence of intestinal perforation complicated by vesicoureteral fistula and umbilical enterocutaneous fistula. Histopathology confirmed the intestinal tuberculosis. The patient was discharged successfully after 11 days post anti-tuberculosis treatment.

Our case report here is a rare case of umbilical intestinal fistula with bladder ileal fistula secondary to intestinal perforation from intestinal tuberculosis. The purpose of this report is to make the surgical community aware of atypical presentations of intestinal tuberculosis. If our peers encounter the similar situation, they can be prepared for corresponding diagnosis and treatment.

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Introduction

Tuberculosis (TB) remains a significant global problem, with an estimated 10.6 million people infected and 1.6 million deaths worldwide in 2021 [ 1 ]. Of these, Children account for 11% of all tuberculosis cases and 14% of all tuberculosis -related deaths [ 2 ].

Intestinal tuberculosis is a chronic specific infection caused by the invasion of Mycobacterium tuberculosis into the intestine, accounting for 1–3% of all TB cases [ 3 ]. Intestinal tuberculosis can lead to serious complications such as intestinal obstruction, perforation, intestinal fistula, intra-abdominal effusion, and gastrointestinal bleeding. The clinical manifestations of intestinal tuberculosis are not obvious, making it difficult to be diagnosed and differentiated from other diseases as well as prone to misdiagnosis.

Here we report a rare case of umbilical enteric fistula and bladder ileal fistula caused by intestinal perforation secondary to intestinal tuberculosis, which was a diagnostic challenge and can only be diagnosed after surgery.

Case report

The patient was an 18-month-old boy, 8.4 kg (2.4 SD lower than peers), who presented with paroxysmal abdominal pain with low-grade fever and diarrhea for 9 days. Physical examination revealed that the patient had a slightly distended abdomen with scattered pressure pain throughout the abdomen, especially in the right lower abdomen. It has a mass with a diameter of 6 cm located in his lower right abdomen. By inquiring about the family medical history, it was known that the grandfather of the patient died due to TB one year ago, and the patient lived with his grandfather. Following, comprehensive laboratory tests had been conducted which included the following index: white blood cell count 18.15 (×10^9/L) ↑, hemoglobin 76 (g/L) ↓, lymphocyte percentage 30.1 (%) ↓, C-reactive protein 30.89 (mg/L) ↑; IL-8 55.84 (pg/mL) ↑; HIV negative; urine routine: red blood cells 48 (pcs/µL) ↑, white blood cells 724 (pcs/µL) ↑, Pus cell mass 39(pcs/µL) ↑; stool routine: leukocytes 3–6(pcs/HP) ↑, positive occult blood test. Abdominal ultrasound suggested a fluid-containing lesion in the right lower abdomen with a viscous composition. Chest X-ray: No obvious abnormality; abdominal X-ray suggested scattered inflation of the small intestine, mainly in the left abdomen. Abdominal CT (Fig.  1 A) indicated abnormal images of the right lower abdomen and pelvis; the intestinal wall was observed more thickened with enhancement. There was the possibility of infectious lesions and abscess formation. The admission diagnosis was considered a peri appendiceal abscess. After admission, the patient was given suspended erythrocytes 0.25U to correct anemia. Symptomatic treatment had been done by employing ceftizoxime and metronidazole for anti-infection and correction of water-electrolyte disturbance, respectively. On day 7 after admission, the patient showed a “fecal-like substance” in his urine. Laboratory tests included: urine routine: bilirubin 17(µmol/L) ↑, protein 0.15(g/L) ↑, erythrocytes 241(g/µL) ↑, leukocytes 709(g/µL) ↑. The urine culture was negative; Gram-positive cocci were found on the urine smear; the urine smear did not show acid-fast bacilli. On day 10, the patient had redness and swelling in the umbilicus with visible secretions. Ultrasound images of the abdomen and umbilicus (Fig.  1 B) showed that mucus composition was observed in the right abdomen, with slow intestinal peristalsis. The partial intestinal dilatation was still visible on the right side of the abdomen; a fluid-containing inflammatory lesion with mucous composition can be seen in the umbilicus, which extended deeper and was seen to be connected to an abscess in the abdominal cavity. On day 14, the patient’s umbilicus was ruptured with visible purulent secretions, and there were still many fecal-like substances in the urine. Retrograde urographic findings (Fig.  1 C) showed that the contrast agent entered the intestinal cavity from the bladder, suggesting the bladder was connected to the intestine, furthermore, ureteral reflux was seen on the left side of the bladder.

Preoperative image examinations

Abdominal CECT: The upper arrow indicates suspicious lesions of the bowel and the lower arrow indicates small mesangial nodules.

Umbilical ultrasound: a liquid inflammatory lesion in the umbilical cord, with a thick component, the lesion extends deeply, and it can be seen to communicate with the intra-abdominal abscess.

Urography: Bladder filling and round-like translucent shadows were observed; The upper arrow indicates contrast is seen in the right abdominal part of the bowel tube, indicating that the bladder may communicate with the intestine; The lower arrow indicates signs of bladder-left ureteral reflux.

On the 15th day of hospitalization, the patient underwent surgical intervention (Fig.  2 ). Under anesthesia, cystoscopy revealed the presence of a fistula at the base of the bladder, prompting further exploration using laparoscopy. Extensive intra-abdominal adhesions were encountered, posing challenges to the surgical dissection, necessitating conversion to open surgery. In the lower right abdomen, a pelvic abscess and miliary granulations were observed. The abscess cavity was meticulously debrided, uncovering an ileal perforation with an associated bladder fistula. To establish bladder diversion, an inflatable catheter was placed in the anterior bladder wall, followed by repair of the bladder defect. Following adhesiolysis, necrotic and partially stenotic segments of the distal ileum were identified, warranting the performance of an ileostomy. Resection of the non-viable bowel segments was performed, and the distal ileum was securely anastomosed. Additionally, an appendectomy was carried out. Thorough irrigation of the abdominal cavity was performed, and a drainage tube was placed for effective drainage. Subsequently, the patient was transferred to the intensive care unit for postoperative management.

Intraoperative images

Bladder wall necrosis is seen, and arrows indicate caseous tissue in the bladder.

The arrow indicates the perforation of the ileum.

Diffuse distribution of white miliary-like particles on the serous membrane is visible.

Based on the above findings, it was suggested that the possibility of abdominal tuberculosis in this patient. Thus, further tests were performed including tuberculosis interferon test, gastric fluid and sputum antacid bacillus smear, gastric fluid and sputum tuberculosis culture, and sputum x-pert all with positive results. Subsequently, pathological findings confirmed abdominal tuberculosis infection by H&E stain (Fig.  3 ). The patient was then transferred to the infection unit to receive continuous anti-tuberculosis (isoniazid 100 mg qd, rifampicin 125 mg qd, linezolid 85 mg tid), intravenous nutrition, and other symptomatic treatments, the patient’s condition was stabilized, and he was successfully discharged from the hospital on the 11th-day post-anti-tuberculosis treatment.

Pathological analysis of ileal mucosal nodules by H&E stain

Image of small nodules of the ileal mucosa.

Image of a granuloma of the mucosa (100-fold).

Image of a granuloma of the mucosa (200-fold).

We explained the very rare pathophysiology of intestinal tuberculosis with intestinal perforation complicated by umbilical intestinal fistula and bladder ileal fistula to the patient’s guardian and obtained informed consent for the case to be published in a medical journal.

Intestinal tuberculosis is a chronic and specific infection caused by Mycobacterium tuberculosis invading the intestine, with abdominal pain, bloating, and weight loss as the primary clinical manifestations [ 4 ]. In infants, this usually occurs through inhalation or ingestion of the mother’s respiratory droplets or through contact with infected breast tissue [ 5 ].

Primary abdominal tuberculosis refers to the direct invasion of abdominal organs and tissues by Mycobacterium tuberculosis during the initial infection, commonly seen in children and immunocompromised individuals. Secondary abdominal tuberculosis, on the other hand, refers to the spread of tuberculous lesions to the abdomen from other sites through the bloodstream or lymphatic system, typically observed in adults and individuals with normal immune function [ 6 ]. The patient, 18 months old, had a family history of tuberculosis. Postoperative pathology confirmed abdominal tuberculosis infection. Chest X-ray did not show any abnormalities. Acid-fast bacilli smear, sputum culture for tuberculosis, and X-pert MTB/RIF assay of the sputum all yielded negative results, suggesting primary abdominal tuberculosis.

Intestinal tuberculosis can lead to severe complications, and a study on intestinal tuberculosis showed a complication rate of 44% (27/61) in 2017, including the formation of abscesses, fistulas, strictures, perforations, and obstructions [ 7 ]. Abdominal symptoms, as the first symptom, is a risk factor for intestinal perforation complicated by abdominal tuberculosis [ 8 ]. The ileocecal region, due to its unique anatomical structure and high absorption rate, is a common site for intestinal perforation in cases of intestinal tuberculosis [ 9 ]. The incidence of intestinal tuberculosis in the ileocecal region is approximately 17–42% [ 10 , 11 ]. In this region, caseous necrosis and abscess formation are commonly observed. The rupture of these abscesses can lead to the dissemination of tuberculosis bacilli to surrounding tissues and organs. One possible route of dissemination is the entry of tuberculosis bacilli into the bladder, resulting in the development of secondary bladder tuberculosis. Bladder tuberculosis typically occurs because of renal tuberculosis, and it is less commonly associated with intestinal tuberculosis. In this scenario, bladder tuberculosis can potentially lead to complications such as enterovesical fistula and bladder perforation [ 12 ].

Diagnosing intestinal tuberculosis is currently a challenge. The insidious onset and nonspecific clinical presentation of intestinal tuberculosis and the lack of expressive skills in children lead to frequent underdiagnosis and misdiagnosis. Therefore, we must combine clinical manifestations, laboratory tests, pathogenic tests, and imaging tests before making a diagnosis.

The clinical symptoms of intestinal tuberculosis are nonspecific, mostly presenting as chronic abdominal pain, and acute abdominal pain is mainly associated with complications [ 13 ]. W. Cheng et al. conducted a retrospective study of 85 patients with intestinal tuberculosis. They found abdominal pain in 75 cases (88.2%), of which 21 cases were acute abdominal pain due to intestinal perforation. The remaining 54 cases presented with Chronic pain around the umbilicus and right lower abdomen [ 14 ]. Patients with intestinal tuberculosis may present with weight loss accompanied by mild to moderate anemia due to various reasons such as chronic inflammatory abscesses, reduced intake, and impaired absorption. Other frequent gastrointestinal symptoms include chronic diarrhea, constipation, and decreased appetite. On physical examination, ascites and palpable abdominal masses are often found, especially in the right lower abdominal region (19.3%) and splenomegaly (14.2%) [ 13 ].

patients with intestinal tuberculosis usually present with elevated ESR, mild to moderate anemia, hypoalbuminemia, and leukocytosis [ 15 ]. W. Cheng et al. concluded that PPD has a high diagnostic value in patients not vaccinated against TB. At the same time, ESR is useful in assessing efficacy, and T-SPOT has a specificity of 92% for TB [ 14 ]. IGRA is highly specific for diagnosing latent tuberculosis infection (LTBI), especially in those who received BCG vaccination [ 16 ]. Continuous CRP values are useful in assessing the response of abdominal tuberculosis to anti-tuberculosis therapy. The absence of a decrease in CRP levels may suggest other diagnoses or drug-resistant TB [ 17 ].

Antacid bacillus staining and Mycobacterium tuberculosis culture are widely used in the diagnosis of intestinal tuberculosis, and it is recommended that this test be routinely performed in patients with intestinal tuberculosis as an indicator to assess response to treatment. Mycobacterium tuberculosis culture is the gold standard for diagnosing intestinal TB, especially for patients who will undergo a colonoscopy and have collected tissue specimens [ 13 ].

Using ultrasound as a diagnostic tool to look for specific features of abdominal tuberculosis is less reliable because of its high false-negative rate and the subjective nature of the manipulation and interpretation of the results, which tend to miss subtle signs [ 18 ]. CT can detect changes within the intestinal wall and complications such as obstruction and perforation, making it an excellent diagnostic tool for intestinal tuberculosis. Intestinal tuberculosis in CECT may present as circumferential wall thickening and increased enhancement of terminal ileum, asymmetric thickening of the ileocecal valve, strictures in distal ileum with upstream bowel loop dilation, and necrotic enlarged lymph nodes in the draining area [ 19 ].

Endoscopy plays an important role in diagnosis by complementing other modalities. it may be the initial tool for diagnosing different symptoms and presentations. An additional benefit of endoscopy is obtaining specimens for histopathologic and microbiologic analysis [ 15 ].

In cases of diagnostic uncertainty, a surgical approach through laparoscopy or dissection may increase the chances of early diagnosis [ 4 ]. Diagnostic laparoscopic exploration combined with tissue biopsy is the gold standard for diagnosing peritoneal tuberculosis, and the typical laparoscopic presentation of peritoneal tuberculosis is: (1) Multiple yellow-white tubercles scattered all over the visceral and parietal peritoneum; (2) Omental thickening with ascites; (3) Fibrous bands extending from parietal peritoneum to visceral peritoneum; (4) Abdominal cocoon with matted small bowel [ 20 ].

Intestinal tuberculosis is characterized by chronic granulomatous inflammation in the gastrointestinal tract, a collection of vaguely contoured epithelioid histiocytes (macrophages), usually large (> 200 μm), confluent, dense (> 5–10/hpf), submucosa, characterized by central caseous changes, which is diagnostic for ITB. Other features commonly seen in ITB include submucosal granulomas, ulcers lined with epithelioid histiocytes, and disproportionate submucosal inflammation [ 21 ]. In our case, the child presented with non-specific abdominal pain symptoms. The diagnosis of a peri appendiceal abscess was considered on admission according to the ultrasound image. He was easily misdiagnosed with peri appendiceal abscess because of the high clinical similarity between the child’s presentation and peri appendiceal abscess.

The treatment approach for intestinal tuberculosis is similar to that of pulmonary tuberculosis and primarily relies on anti-tuberculosis drug therapy. According to the World Health Organization (WHO) recommendations, the treatment regimen for pediatric tuberculosis includes medications such as isoniazid, rifampicin, pyrazinamide, and ethambutol. The recommended dosages are isoniazid 10–15 milligrams/kilogram, rifampicin 10–20 milligrams/kilogram, pyrazinamide 30–40 milligrams/kilogram, and ethambutol 15–25 milligrams/kilogram. The treatment duration consists of an initial intensive phase of two months followed by a continuation phase of four months to ensure the eradication of Mycobacterium tuberculosis [ 22 ]. For cases of multidrug-resistant tuberculosis, linezolid has been proven to be an effective treatment option with bactericidal activity and the ability to penetrate the cerebrospinal fluid. However, its use is limited by toxicity and the need for long-term monitoring. Therefore, further research is required to determine the optimal dosage and duration of treatment to achieve the best efficacy-toxicity balance [ 23 ]. To ensure the complete eradication of tuberculosis (TB), we adopted a long-course anti-tuberculosis treatment lasting for a total of 9 months. This treatment regimen consists of an initial intensive phase, which includes 1 month of isoniazid 100 mg qd, rifampicin 125 mg qd, and ethambutol 85 mg tid, followed by a maintenance phase that includes isoniazid 100 mg qd and rifampicin 125 mg qd.

To achieve the best therapeutic outcome, it is crucial to adhere to the full duration of the treatment course. The extended treatment duration aims to effectively eliminate TB infection and prevent the development of drug resistance. Close monitoring and regular follow-up are essential to evaluate the response to treatment and address any potential adverse effects.

Although pharmacologic anti-tuberculosis can treat most patients with intestinal TB, surgical treatment is necessary when severe complications such as intestinal obstruction, intestinal adhesions, and intestinal degeneration due to intestinal tuberculosis occur [ 24 ]. In patients with abdominal tuberculosis who have developed severe complications, the indications for surgery can be relaxed, and surgery should be performed as early as possible [ 25 ].

In our case, the child had developed severe complications. The etiological diagnosis was unclear, so we performed a laparoscopic exploration of the child. However, we found extensive intra-abdominal adhesions intraoperatively, which were challenging to separate laparoscopically, and we decided to convert to open surgery. The etiology of the abdominal infection in this child was unknown, and the possibility of abdominal tuberculosis infection was considered in combination with his low weight, hypothermia, and combined with his family history. We decided to treat the child with diagnostic anti-tuberculosis treatment with signed consent from his family. Finally, pathological sections confirmed intestinal tuberculosis infection to support our decision. After 11 days of anti-tuberculosis treatment, the patient’s condition stabilized, and they were successfully discharged. Follow-up visits were conducted for a total of 8 months after discharge, during which the patient’s general condition recovered satisfactorily, and their weight increased to 11.7 kg (below 1 SD for age). The cystostomy tube was removed 3 days after discharge. We did monthly follow-ups for the patient there was no liver function impairment. The patient developed an adhesive intestinal obstruction in the 6th month postoperatively. Fasting, rehydration, and supportive treatments were conducted for five days, the patient was then in remission and then discharged. The current treatment plan is to evaluate whether to discontinue anti-tuberculosis treatment after 9 months. The ileostomy closure was initially proposed one year after.

In conclusion, the case presented here is a rare case of umbilical-enteric fistula with bladder ileal fistula secondary to intestinal perforation from intestinal tuberculosis. this article aims to make the surgical community aware of this atypical presentation of intestinal tuberculosis so that they can be prepared in case they encounter it in the future.

Data Availability

The datasets for this article are not publicly available due to concerns regarding participant/patient anonymity. Requests to access the datasets should be directed to the corresponding authors.

Abbreviations

Bacillus Calmette Guerin

C-reactive protein

Computed Tomography

Contrast-enhanced computed tomography

Erythrocyte sedimentation rate

Human Immunodeficiency Virus

High Power Field

Hematoxylin-Eosin staining

Interferon-gamma release assay

Interleukin-8

• Intestinal tuberculosis

Latent tuberculosis infection

Purified protein derivative

Standard deviation

Tuberculosis

X-pert MTB/RIF(Mycobacterium Tuberculosis/ Rifampicin)

Stephenson J. WHO Report: years of progress in global tuberculosis upset by COVID-19 pandemic. JAMA Health Forum. 2022;3(11):e224994.

Article   PubMed   Google Scholar  

Li T, et al. Childhood TB in China: notification, characteristics and risk factors for outcomes, 2010–2017. Int J Tuberculosis Lung Disease: Official J Int Union Against Tuberculosis Lung Disease. 2020;24(12):1285–93.

Article   CAS   Google Scholar  

Eraksoy H. Gastrointestinal and abdominal tuberculosis. Gastroenterol Clin North Am. 2021;50(2):341–60.

Sartoris G, et al. Abdominal tuberculosis in children: Challenges, uncertainty, and confusion. J Pediatr Infect Dis Soc. 2020;9(2):218–27.

Article   Google Scholar  

Adela Matettore M, FRCPC, FAAP,*† Meghna Rajaprakash, MSc, MD,†‡ Mary Bennett, MD, FRCPC,*† Erik D. Skarsgard, MD, FRCSC, FACS,‡§ and Ran, Goldman D, FRCPC†| MD. Abdominal Tuberculosis in an Infant Presenting With a Small Bowel Obstruction Pediatric Emergency Care, 2019;00(00):00.

Lazarus AA, Thilagar B. Abdominal tuberculosis. Dis Mon. 2007;53(1):32–8.

Kentley J, et al. Intestinal tuberculosis: a diagnostic challenge. Trop Med Int Health: TM IH. 2017;22(8):994–9.

Article   CAS   PubMed   Google Scholar  

Gui-hui. L.L.Z.L.-p.X.F.-h.C.Q.W., retrospective study on risk factors for concurent intestinal perforation in patients with abdominal tuberculosis . Chin J Antituberc. 2022;44(1):71–7.

Google Scholar  

Masood I et al. Multiple, Pan-Enteric Perforation Secondary to Intestinal Tuberculosis Case Rep Surg, 2015;318678.

Burke KA, et al. Diagnosing abdominal tuberculosis in the acute abdomen. Int J Surg. 2014;12(5):494–9.

Ramesh J, Banait GS, Ormerod LP. Abdominal tuberculosis in a district general hospital: a retrospective review of 86 cases. QJM. 2008;101(3):189–95.

Muneer A, et al. Urogenital tuberculosis - epidemiology, pathogenesis and clinical features. Nat Rev Urol. 2019;16(10):573–98.

Maulahela H, et al. Recent advances in the diagnosis of intestinal tuberculosis. BMC Gastroenterol. 2022;22(1):89.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Cheng W, et al. Intestinal tuberculosis: clinico-pathological profile and the importance of a high degree of suspicion. Trop Med Int Health. 2019;24(1):81–90.

Al-Zanbagi AB, Shariff MK. Gastrointestinal tuberculosis: a systematic review of epidemiology, presentation, diagnosis and treatment. Saudi J Gastroenterol. 2021;27(5):261–74.

Article   PubMed   PubMed Central   Google Scholar  

Jung HJ, et al. Differences in clinical manifestations according to the positivity of Interferon-gamma assay in patients with intestinal tuberculosis. Gut Liver. 2016;10(4):649–52.

Sharma V, et al. Serial C-reactive protein measurements in patients treated for suspected abdominal tuberculosis. Dig Liver Dis. 2018;50(6):559–62.

Van Hoving DJ, et al. Abdominal ultrasound for diagnosing abdominal tuberculosis or disseminated tuberculosis with abdominal involvement in HIV-positive individuals. Cochrane Database Syst Rev. 2019;9:CD012777.

PubMed   Google Scholar  

Dawani A, Gupta AK, Jana M. Imaging in Pediatric Extra-Pulmonary Tuberculosis. Indian J Pediatr. 2019;86(5):459–67.

Arvind S, et al. Laparoscopic diagnosis of peritoneal tuberculosis. J Minim Invasive Gynecol. 2019;26(2):346–7.

Kedia S, et al. Differentiating Crohn’s disease from intestinal tuberculosis. World J Gastroenterol. 2019;25(4):418–32.

Carvalho I, et al. Managing latent tuberculosis infection and tuberculosis in children. Pulmonology. 2018;24(2):106–14.

Huynh J, et al. Tuberculosis treatment in children: the changing landscape. Paediatr Respir Rev. 2020;36:33–43.

Li Jun BJ, Xueyang Z. The study of surgical treatment of peritoneal tuberculosis. Contemp Med. 2018;24(14):57–8.

Xu Huihai, Li Yazhai, Li Zijian, Li Mingzhu DX. Qi Hailiang., Clinical Analysis of Surgical Treatment of Abdominal Tuberculosis Sichuan Medical Journal, 2020;41(11):1117–1120.

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Department of General Surgery and Trauma Surgery, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children’s Hospital of Chongqing Medical University, 400014, Chongqing, China

Guobin Liu, Tianyan Chen, Xiaofeng Song, Bolin Chen & Quan Kang

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KQ, L-GB, and C-TY conceptualized the manuscript and participated in the revisions. L-GB, C-BL, and S-XF were involved in the acquisition of all the clinical data. L-GB, C-TY, and KQ were involved in the drafting of the manuscript and analyzed the literature. KQ, L-GB, and C-TY participated in the revisions. All authors approved the final version of the manuscript.

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Correspondence to Quan Kang .

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Written informed consent was obtained from the patient’s guardian for the publication of this case report and the accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal upon request.

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Liu, G., Chen, T., Song, X. et al. Case report: a case report and literature analysis on intestinal tuberculosis intestinal perforation complicated by umbilical intestinal fistula and bladder ileal fistula. BMC Infect Dis 23 , 559 (2023). https://doi.org/10.1186/s12879-023-08550-z

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DOI : https://doi.org/10.1186/s12879-023-08550-z

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Chief Complaint

“I have a cough that won’t go away.”

History of Present Illness

A 63-year-old male presents to the emergency department with complaints of cough/shortness of breath which he attributes to a “nagging cold.” He states he fears this may be something worse after experiencing hemoptysis for the past 3 days. He also admits to waking up in the middle of the night “drenched in sweat” for the past few weeks. When asked, the patient denies ever having a positive PPD and was last screened “several years ago.” His chart indicates he was in the emergency department last week with similar symptoms and was diagnosed with community-acquired pneumonia and discharged with azithromycin.

Past Medical History

Hypertension, dyslipidemia, COPD, atrial fibrillation, generalized anxiety disorder

Surgical History

Appendectomy at age 18

Family History

Father passed away from a myocardial infarction 4 years ago; mother had type 2 DM and passed away from a ruptured abdominal aortic aneurysm

Social History

Retired geologist recently moved from India to live with his son who is currently in medical school in upstate New York. Smoked ½ ppd × 40 years and drinks 6 to 8 beers per day, recently admits to drinking ½ pint of vodka “every few days” since the passing of his wife 6 months ago.

Sulfa (hives); penicillin (nausea/vomiting); shellfish (itching)

Home Medications

Albuterol metered-dose-inhaler 2 puffs q4h PRN shortness of breath

Aspirin 81 mg PO daily

Atorvastatin 40 mg PO daily

Budesonide/formoterol 160 mcg/4.5 mcg 2 inhalations BID

Clonazepam 0.5 mg PO three times daily PRN anxiety

Lisinopril 20 mg PO daily

Metoprolol succinate 100 mg PO daily

Tiotropium 2 inhalations once daily

Venlafaxine 150 mg PO daily

Warfarin 7.5 mg PO daily

Physical Examination

Vital signs.

Temp 100.8°F, P 96, RR 24 breaths per minute, BP 150/84 mm Hg, pO 2 92%, Ht 5′10″, Wt 56.4 kg

Slightly disheveled male in mild-to-moderate distress

Normocephalic, atraumatic, PERRLA, EOMI, pale/dry mucous membranes and conjunctiva, poor dentition

Bronchial breath sounds in RUL

Cardiovascular

NSR, no m/r/g

Soft, non-distended, non-tender, (+) bowel sounds

Genitourinary

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HIV-TB co-infection with clinical presentation, diagnosis, treatment, outcome and its relation to CD4 count, a cross-sectional study in a tertiary care hospital in coastal Karnataka

Jutang babat ain tiewsoh.

Department of Microbiology, Fr. Muller Medical College, Kankanady, Mangalore, Karnataka, India

Beena Antony

Rekha boloor, introduction:.

Tuberculosis (TB) is the leading killer and the commonest opportunistic infection (OI) in human immunodeficiency virus (HIV) infected individuals with 0.3 million deaths in 2017. When HIV and TB co-infection occurs, they form a deadly combination with each accelerating the progression of the other, resulting in increased morbidity and mortality.

Aim and Objectives:

To study the demographic pattern, clinical presentation, opportunistic infections, radiological and laboratory profile, management, and outcome of HIV-TB coinfected individuals.

Materials and Methods:

A prospective cross-sectional study was carried out on confirmed HIV cases already diagnosed with TB and those newly detected with TB after admission, where diagnosis was carried out following standard operative procedures.

In our study of 58 HIV-TB co-infected individuals, 40–50 years was the most common age group affected. Males were affected more with majority being married. The most common presentation was fever (67%) followed by gastrointestinal symptoms. Majority of TB cases were newly diagnosed (65.5%), with predominance of pulmonary tuberculosis (PTB) ( n = 35) followed by those having only extrapulmonary tuberculosis (EPTB) ( n = 12) and both ( n = 11). TB was diagnosed by microscopy in 32.7%, while radiologically, chest X-ray was most common (36.2%). Also, 50% were infected with other OIs where oral candidiasis was the most common (37.93%). The overall mean CD4 count was 220 cells/μL and those with EPTB had lesser CD4 counts than those with PTB. All were on DOTS regimen and majority showed improvement.

Conclusion:

In a country like India where both these diseases are rampant, we recommend better information, education, understanding and awareness for prevention, care, early diagnosis, and treatment of these two notorious infectious diseases with prevention of relapse and default of TB cases in HIV-TB co-infected individuals a priority.

Introduction

Tuberculosis is without a doubt the most common OI and causes majority of deaths in HIV infected individuals.[ 1 , 2 , 3 , 4 , 5 ] According to World Health Organization (WHO) estimates in 2017, 10 million got infected with TB out of which 1.6 million succumbed, of which 0.3 million was accounted by those people diagnosed with HIV, although the rate has decreased when compared with 2005, when it was at its peak.[ 3 , 5 ] India contributes about one-fourth of the global TB burden with the highest burden of both TB and MDR TB and the country is second only to South Africa for the highest estimated HIV-TB cases.[ 6 ]

In 2017, globally there were 1.8 million newly infected cases of HIV which claimed an estimated 940,000 lives and till date > 35 million lives have been lost.[ 4 ] When HIV-TB occurs in combination they accelerate the progression of each other and the risk of death is increased by two times than those infected with HIV alone.[ 4 , 7 ] In HIV-infected individuals, TB occurs early in the course of infection and the rate of developing active TB is about 20–30 times.[ 3 , 7 ]

The classic symptoms of TB may be present in HIV patients co-infected with PTB but some may not. Also, co-infection leads to difficulty in both diagnosis and treatment of TB.[ 5 , 7 , 8 ] Majority of people with HIV have a negative sputum smear resulting in large number of active TB infection cases going undiagnosed and due to lack of proper treatment, death may occur on an average in 45% of sero-negative HIV people with TB and nearly in all coinfected cases of HIV-TB.[ 3 ]

Studies in relation to HIV-TB coinfection is lacking from in and around Mangalore. Hence, this study was conducted to study the demographic pattern, clinical presentation, OIs/co-infections, radiological, laboratory profile, management, and outcome in HIV-TB co-infected individuals, so as to have a better understanding of what is really happening in relation to those coinfected with these two infections and guide clinicians and healthcare workers in providing appropriate management and treatment to such cases.

Materials and Methods

A prospective cross-sectional study was conducted in a tertiary care teaching hospital in coastal Karnataka, India, for a period of 2 years from August 2013 to July 2015 where Ethical clearance was obtained from the Institutional Ethics Committee. Inform consent was taken from study participants willing to participate in the study.

Determination of HIV Status

All persons included in the study were symptomatic confirmed cases of HIV detected according to defined strategies following NACO guidelines where a screening rapid test (HIV Tridot, J. Mitra and Co., India) was used and confirmed by fourth generation ELISA (J. Mitra and Co.).[ 9 ]

WHO Tuberculosis Case Definition

”A bacteriologically confirmed TB case is one from whom a biological specimen is positive by smear microscopy, culture or WRD (such as Xpert MTB/RIF).”[ 10 ]

”A clinically diagnosed TB case is one who does not fulfil the criteria for bacteriological confirmation but has been diagnosed with active TB by a clinician or other medical practitioner who has decided to give the patient a full course of TB treatment. This definition includes cases diagnosed on the basis of X-ray abnormalities or suggestive histology and extrapulmonary cases without laboratory confirmation.”[ 10 ]

Inclusion criteria

• HIV positive cases already diagnosed to have TB on admission and on treatment
• HIV positive cases detected having TB on investigation after admission.

All those fulfilling the inclusion criteria and willing to participate during the study period were included in the present study and hence no bias.

Tuberculosis was diagnosed by the following investigations:

• Acid fast bacilli (AFB) staining by Ziehl-Neelsen (ZN) method for given appropriate sample and culture done where ever indicated
• Fluorescent staining by auramine rhodamine stain done in a DOTS laboratory attached to our institute
• Radiological diagnosis by chest X-ray, magnetic resonance imaging (MRI), computed tomography (CT) scan, and ultrasound with features suggestive of tubercular lesions
• Cerebrospinal fluid (CSF) analysis showing predominant lymphocyte count with low glucose level.

Investigations for the diagnosis of other OIs when suspected were also carried out. CD4 counts were obtained from ICTC center and Wenlock District hospital, Mangalore. A detailed clinical history on presentation with complete examination findings and outcome were also recorded.

Statistical analysis

The data were collected and then analysed using IBM SPSS Statistics for Windows, version 22 (IBM Corp., Armonk, NY) where representation of discrete categorical data was in the form of either a number or a percentage (%) and group (pulmonary tuberculosis [PTB] present/absent), (extrapulmonary tuberculosis [EPTB] present/absent) comparisons by Chi-square test or Fisher's exact test. Continuous data were represented as mean ± SD, range or median and interquartile range, as appropriate. Measures of Kolmogorov Smirnov tests of normality were done to check the normality of quantitative data. P < 0.05 was considered statistically significant.

During the study period, 137 HIV-infected individuals diagnosed with different OIs who were willing to participate in the study were enrolled out of which 58 were found to be co-infected with TB, where the most common age group affected were of the 40–50 years age group ( n = 23; 40%) followed by > 50 years ( n = 14; 24%), 30–40 years ( n = 13; 22%), and <30 years ( n = 8; 14%). Males were affected more than females in a ratio of 3.46:1 (45:13) with majority being married ( n = 46; 73%) followed by single ( n = 10; 17%) and widowed ( n = 2; 4%), while known cases of HIV was 48.27% ( n = 28) and those on ART treatment was 43% ( n = 25). The most common presentation was fever ( n = 39; 67%) followed by gastrointestinal symptoms such as loss of appetite, vomiting, diarrhea, nausea, dysphagia, and pain abdomen present in 56.8% ( n = 33). Respiratory symptoms such as breathlessness and cough were present in 51.7% ( n = 30) followed by generalized weakness present in 37.9% ( n = 22), whereas central nervous system symptoms such as headache, convulsions, and altered sensorium were present in 36.2% ( n = 21) and others like weight loss ( n = 19) and lymphadenopathy ( n = 11) were also seen. Also, patients were seen to have pleural effusion ( n = 8) and ascites ( n = 8).

In our study, we also observed that majority of TB cases were newly diagnosed ( n = 38; 65.5%), while known cases of TB on treatment was 24% ( n = 14) and relapse of TB occurred in 10.34% ( n = 6). We also found that majority were diagnosed as PTB ( n = 35; 60%) followed by those having only EPTB ( n = 12; 21%), whereas the rest had both PTB and EPTB ( n = 11; 19%).

The diagnosis of TB was done by microscopy in 32.7% ( n = 19). ZN staining samples included sputum, pus, biopsy, and urine ( n = 11) while fluorescent microscopy in DOTS center were of sputum samples only ( n = 8). Radiologically for diagnosis, chest X-ray was the most commonly used out of which 36.2% ( n = 21) had chest X-ray changes suggestive of TB while TB changes by CT scan ( n = 9), MRI ( n = 5) and ultrasonography ( n = 4) were also seen. Gene Xpert was positive only in two patients were in one MTB detection was low and the other medium, whereas no rifampicin resistance was detected in both.

Laboratory investigations of CSF of eight ( n = 8) suspected TB meningitis patients showed mean values of CSF glucose is 50.8 mg/dL (40–70 mg/dL), CSF protein 371.2 mg/dL (15–45 mg/dL), CSF chloride 96.5 mEq/L (120–130 mEq/L), CSF Adenosine deaminase 31.8 IU/L (up to 10 IU/L) and predominance of lymphocytes mean value at 84% compared with neutrophils at 16%.

In our study, 50% ( n = 29) were infected with HIV and TB only, whereas another half ( n = 29; 50%) were coinfected with other OIs. For which the most common was oral candidiasis found in 37.93% ( n = 22) followed by hepatitis B virus [HBV in ( n = 3)], toxoplasmosis ( n = 3), cryptococcus ( n = 2), and cytomegalovirus ( n = 2). A combination of HIV/TB with one OI was seen in 46.5% ( n = 27) and with two OIs in 3.4% ( n = 2).

In relation to CD4 count which was available only for 27 patients, the overall mean value was 210 cells/μL and majority had values of <250 cells/μL ( n = 19) and the rest > 250 cells/μL ( n = 8). The mean value for patients with PTB ( n = 18) was 230 cells/μL, whereas those who had EPTB ( n = 7) was 166.8 cells/μL and those who were diagnosed having both ( n = 2) had a mean value of 220 cells/μL where one had a CD4 count value of 104 cells/μL and the other 336.l cells/μL.

Hemoglobin levels which were available for only 56 patients showed that majority had anemia (69%, n = 40), whereas 27.5% ( n = 16) had normal levels. Severe anemia (<7 g/dL) was seen in 6.9% ( n = 4), moderate anemia (7 to <10 g/dL) in 37.9% ( n = 22) and mild anemia (10–11.5 g/dL) in 24.1% ( n = 14). All patients were undergoing/started treatment by DOTS (directly observed treatment, short course) regimen for which majority (82.75%, n = 48) were on Category I and 17.2% ( n = 10) on Category II where the overall hospital stay of patients was 8.6 days. It was also observed that majority showed improvement ( n = 47.81%), whereas 16% ( n = 9) left against medical advice and only 3% ( n = 2) expired. A flowchart of the findings have been summarised in [ Figure 1 ].

Flowchart summarizing the results of the study

In this present study where 58 HIV-TB co-infected individuals were included, we found that 40–50 years age group were most affected which is of a higher age group when compared to other studies who had reported 30–40 years age group to be the most common.[ 11 , 12 , 13 ] We believe that with the availability of antiretroviral therapy, it has resulted in decreased mortality and morbidity in these HIV infected individuals, which, in turn, has led to prolonged life where it has also been observed that PLHIV was 8.74 million in 1990 which has increased to 36.82 million in 2017.[ 14 , 15 ]

Also, males were found to be more commonly affected than females in a ratio which is also similar to other studies[ 12 , 13 , 16 , 17 , 18 , 19 , 20 ] where in a study conducted by Kumar P et al ., they had even reported a very high male to female ratio of 9:1.[ 21 ] Majority of our participants were married which is also similar to other studies.[ 11 , 12 , 22 ]

The most common presentation was fever followed by gastrointestinal and respiratory symptoms, but Kumar et al . had reported respiratory symptoms like cough and expectoration to be more common followed by fever and gastrointestinal features.[ 21 ] The rate of CNS symptoms which were encountered in our study was very high when compared with Kumar et al . who had reported only in 7.2%.[ 21 ]

In our study, we also observed that majority were newly diagnosed HIV-TB co-infection while relapse of TB occurred in 10% which is similar to findings of Shastri et al . who found in their study for the state of Karnataka as a whole with available data from all the ART centers of the state that majority were new TB cases and relapse occurred at a rate (9.6%), which is very similar to our finding.[ 18 ] One should keep in mind that these relapse cases might also be due to reinfection with TB or a true relapse fitting the WHO definition.[ 10 ] Narayanan et al . also reported that the recurrence of TB in co-infected individuals was caused by a new strain of TB in 88%, whereas TB recurrence in HIV uninfected individuals was caused by the same strain in 91%.[ 23 ] Crampin et al . also concluded that the high recurrence rate of TB in HIV-infected individuals is due to reinfection and not relapse.[ 24 ]

We also found that majority were diagnosed with PTB where similar findings were reported by Kamath et al .[ 22 ] who had reported PTB (59%) to be the most common presentation followed by EPTB (38%) and those having both (3%) and even Shastri et al . had reported that in Karnataka state PTB was found in nearly three-fourths of co-infected individuals.[ 18 ] But other studies have reported that EPTB to be more common than PTB,[ 13 , 16 , 19 , 21 ] whereas some studies had reported nearly equal percentages for both PTB and EPTB.[ 17 , 20 ] The number of individuals in our study having both PTB and EPTB was nearly 20% which is similar to the finding by Maniar et al .,[ 17 ] but Kumar et al . had reported at a rate of 35.6% which is very high.[ 21 ]

Microscopy positivity which included both ZN and fluorescent microscopy for diagnosis was 32.7%, which was similar to findings of Maniar et al .[ 17 ] who reported 36.5%, whereas Kamath et al .[ 22 ] reported very high positivity of 43% but Ghiya et al . reported only 2.4% positivity.[ 12 ] Radiologically, chest X-ray was the most common modality which was used for diagnosis which is similar to other studies[ 12 , 17 , 21 ] USG sensitivity in our study was less when compared with other studies.[ 12 , 17 ] GeneXpert which was introduced in our Institute at nearly the end of our study could detect two cases which were both sensitive to Rifampicin. Laboratory investigations of CSF showed high mean values for protein and ADA with predominance of lymphocytes which are diagnostic of TB meningitis in 13.7% ( n = 8) of all patients while Ghiya et al . reported in 5%.[ 12 ]

TB among all OIs is the commonest in HIV infected individuals but other OIs frequently infect such patients.[ 1 , 2 ] In our study, we found that half of the total number of HIV-TB co-infected individuals were also co-infected with other OIs of which oral candidiasis was the most common followed by HBV and toxoplasma which is similar to findings of Maniar et al . who reported predominance of oral candidiasis among the OIs and cases of cerebral toxoplasmosis (4.9%) and HBV (8.2%) were also reported.[ 17 ] Vohra et al . also observed that oral candidiasis was the most common oral manifestation in HIV patients.[ 25 ]

In relation to the CD4 count which was available for half of the patients, it was found that it is similar to other studies[ 16 , 18 ] who also reported decreased CD4 values but we found that those having EPTB had a lower mean CD4 value than those who were diagnosed with PTB alone but Sharma et al . observed that in HIV patients co-infected with PTB or EPTB, the median CD4 showed no significant difference.[ 16 ] Also, Kamath et al . found that the mean CD4 count at initial presentation was 174.47 cells/μL which after treatment of 6 months increased to 300 cells/μL and they had concluded that when compared to those infected with HIV alone the CD4 counts of co-infection was very much low.[ 22 ] Majority in our study had CD4 counts <250 cells/μL, which is similar to findings of other studies.[ 11 , 20 ]

Anemia was present in nearly three fourths of our patients, findings similar to Patil et al .[ 1 ] who reported anemia to be present in 94% of HIV patients, whereas Sobhani et al . concluded that Hb levels <7 g/dL were associated with increased mortality in HIV infected individuals.[ 26 ]

All patients were either undergoing or started on DOTS treatment which showed the effectiveness of the program which was possible since we have a DOTS center attached to our institute which is similar to a study by Kamath et al . who conducted in an ART center in South India, where they found 97.2% of those infected with HIV-TB were under DOTS therapy but without a doubt the worrying part is that nearly one-fifth of the cases were on category II treatment.[ 22 ]

Majority of our patients showed improvement on discharged, while only 3% expired during hospital stay which is much better than Shastri et al .[ 18 ] who reported as high as 15% and Sharma et al . as high as 13.2% mortality.[ 16 ] Our findings might have been affected by the fact that 16% left against medical advice and their outcome is unknown, which would be a limitation of the study.

Role of primary care physician

Primary care physicians are the first to see patients who will be presenting with a wide variety of presentation ranging from mild to severe diseases and the ones likely to diagnose or suspect patients with either HIV or TB or both. Hence, they can guide them to obtain diagnosis, treatment from nearest ART centers, and also in giving prophylaxis for the prevention of OIs.

Also, the rate of depression in a study conducted in China, among HIV-infected individuals was as high as 50.6% compared with 7.6% for general population. So, with an increase in PLHIV in 2017 compared with 1990, primary care physicians will not only have to deal with the known effects of these two diseases but also with others related to it like depression, anxiety disorders, long-term treatment, and life-long infection and ensure that PLHIV can lead a healthy life beyond viral suppression.[ 14 , 27 ]

In our study, we observed that most commonly affected are those of 40- to 50-year age group, married, and males. They generally present with fever. Majority being newly diagnosed cases of TB, where PTB was more common than EPTB and oral candidiasis being the most common OI seen. The overall mean CD4 count was 220 cells/μL and counts for those diagnosed with EPTB was lesser than those of PTB. Even though all were already on or started with DOTS regimen, the worrying part is that 17.2% were on category II treatment and many left against medical advice. In conclusion, in a country like India where both these diseases are rampant, we recommend better information, education, understanding, awareness, and early diagnosis of these two notorious infectious diseases with prevention of relapse and default of TB cases in HIV-infected individuals a priority.

Research Quality and Ethics Statement

The authors of this manuscript declare that this scientific work complies with reporting quality, formatting and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation was determined to require the Institutional Review Board/Ethics Committee review, and the corresponding protocol/approval number is FMMC/FMIEC/1447/2013. Finally, the authors also certify that we have not plagiarized the contents in this submission and have done a Plagiarism Check.

Financial support and sponsorship

Father Muller Medical College and Hospital, Mangalore where study participants were encountered and the present study is a part of the dissertation submitted to Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka, in partial fulfilment of the requirements for the award of the degree of Doctor of Medicine (MD) in Microbiology.

Conflicts of interest

There are no conflicts of interest.

Acknowledgements

We are grateful to Dr. Kishore Kumar M. [District AIDS Prevention and Control Unit (DAPCU) officer], District Wenlock Hospital, Mangalore for helping us in recording the CD4 counts of individuals in the study and Mrs Suchitra Suresh, Lecturer in Statistics, FMMCH, Mangalore for carrying out the statistical work of the study.

Treatment of mixed and refractory post-tuberculosis tracheobronchial stenosis with L-shaped silicone stents: case series and a literature review

Affiliations.

• 1 Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Guangxi Medical University, Nanning, China.
• 2 The Second Affiliated Hospital of Guangxi Medical University, No. 166, Daxue Road, Nanning, Guangxi Province, Xixiangtang District, Nanning 530000, China.
• PMID: 38785036
• PMCID: PMC11119346
• DOI: 10.1177/17534666241254901

The two patients included in the study had mixed and refractory post-tuberculosis tracheobronchial stenosis (PTTS), having experienced unsuccessful interventional therapies such as balloon dilation and V-shaped stent placement before the operation. Following the secure placement of L-shaped silicone stents, examinations with a fiberbronchoscope during the first and third months post-operation revealed a significant reduction in bronchial mucosa inflammation for both patients. Additionally, the opening diameter of the upper and lower branch segments increased, and chest CT scans indicated a noticeable absorption of left pulmonary lesions. Three months post-operation, fiberbronchoscopy confirmed the stable fixation of the stent without any movement. The patients exhibited substantial improvements in pulmonary function, dyspnea index, and blood gas analysis, with no reported adverse complications. After 7 months, a follow-up fiberbronchoscope for one case revealed excellent stent fixation. Simultaneously, the chest CT scan indicated favorable re-expansion. The placement of L-shaped silicone stents proves effective in preventing displacement, alleviating airway stenosis or obstruction, and ensuring the safety and efficacy of PTTS treatment - particularly in cases where V-shaped silicone stent placement has failed. To our knowledge, this is the first study describing the L-shaped silicone stent in two patients with PTTS.

Keywords: L-shaped silicone stent; mixed bronchial tuberculosis; refractory bronchial tuberculosis; rigid bronchoscopy.

Plain language summary

Successful treatment of severe airway narrowing due to tuberculosis using special L-shaped silicone stents This article tells the story of two patients who suffered from a complex lung condition called post-tuberculosis tracheobronchial stenosis (PTTS). Imagine your airways - the tubes that carry air to your lungs - getting severely scarred and narrowed due to a past bout with tuberculosis. These two patients had tried previous treatments like balloon dilation (where a small balloon is inflated inside the narrowed airway to widen it) and using V-shaped stents (flexible supports placed in the airway to keep it open), but these methods didn’t provide lasting relief. In this innovative approach, doctors used L-shaped silicone stents specifically designed to fit in the affected parts of the patients’ airways. After placing these stents, regular checks showed remarkable improvements. The swelling in the airway lining reduced significantly, and the openings leading to the upper and lower parts of the lungs got wider. Chest X-rays (CT scans) even showed that the patient’s left lung was healing well. Three months later, the stents stayed firmly in place, and neither patient experienced any problems. Breathing became easier, lung function tests improved, and blood tests showed better oxygen levels. Seven months down the line, one patient continued to do extremely well, with the stent securely fixed and the chest scan showing good lung expansion. This groundbreaking study shows that using L-shaped silicone stents can effectively treat PTTS when other methods fail. Not only do they stay in place, preventing blockages, but they also safely and effectively alleviate narrowing of the airways. It’s the first time such L-shaped stents have been used successfully in PTTS patients, offering new hope for those facing similar challenges.

Publication types

• Case Reports
• Bronchial Diseases* / etiology
• Bronchial Diseases* / physiopathology
• Bronchial Diseases* / therapy
• Bronchoscopy* / instrumentation
• Constriction, Pathologic
• Middle Aged
• Prosthesis Design
• Tomography, X-Ray Computed
• Tracheal Stenosis* / etiology
• Tracheal Stenosis* / therapy
• Treatment Outcome
• Tuberculosis, Pulmonary / complications