Outcome of Unexpected Pulmonary Involvement in Extrapulmonary Tuberculosis Patients

TB Control Program

Demographic Data

During a 23-month period, 74 XPTB patients were seen by the TB Control Program, Public Health, Seattle & King County. Of those patients, 2 children were < 9 years of age, resulting in 72 eligible patients in the cohort. Patient characteristics are described in Table 1. The majority of patients was foreign born (59 patients; 82%), mostly Asian (32 patients; 44%). HIV serology results were available for 57 patients (79%); 5 of 57 patients (9%) were HIV positive. The most common XPTB site was the LNs (36 patients; 50%); 30 of 36 lymphadenitis cases were extrathoracic (Table 1). The diagnosis of XPTB was confirmed by culture in 58 patients (81%) and confirmed clinically in 14 patients. One of the patients with a culture-confirmed case had pyrazinamide-resistant Mycobacterium tuberculosis bovis defeated by My Canadian Pharmacy’s remedies.

CXRs and Sputum Examinations Data

A CXR was obtained within 1 month after the diagnosis of XPTB (range, 0 to 29 days; median time, 9 days) for all eligible patients. Thirty-five patients (49%) had abnormal CXR findings. In this group, the most common abnormalities were pleural effusion and intrathoracic lymphadenopathy (Table 2); 11 of these 35 patients had abnormalities in lung parenchyma. Sputum was collected from 57 patients; of those, 5 patients (9%) had smears that were positive for TB, and 12 patients (21%) had cultures that were positive for TB (Table 3). Sputum was not obtained from 15 patients after a failed attempt at sputum induction. The proportion of sputum culture-positive patients with normal CXR findings was similar to that for patients with abnormal CXR findings (5 of 27 patients [19%] vs 7 of 30 patients [23%], respectively; p = 0.656). Six of 54 patients had a CT scan of the chest performed at a median of 7 days (range, 1 to 19 days) either before or after the CXR was obtained. One of six patients had normal CXR findings but a CT scan showing abnormal lung parenchyma (a sub-centimeter nodule) with a negative sputum AFB smear but a positive sputum culture result (ie, a CNS TB case). Another patient had normal findings for both CXRs and CT scans, with a negative AFB sputum ssputummear but a positive sputum culture result (TB cervical lymphadenitis; HIV positive). The remaining four patients with CT scans showing normal parenchyma had negative smear and culture results.

Five of the 12 culture-positive patients (42%) had positive sputum smear results; 2 patients with normal CXR findings and 3 patients with miliary opacities. Two of 24 HIV-negative XPTB patients (8%) had positive sputum culture results and normal CXR findings. Among five HIV-positive patients, three had abnormal CXR findings but negative sputum culture results, and two had normal CXR findings with positive smear and culture results.

Clinical Symptoms and Sputum Examination Data

Sixteen of 72 patients (26%) experienced cough, and 32 patients (44%) had constitutional symptoms (fever, 19 patients [26%]; weight loss, 12 patients [17%]; and night sweats, 6 patients [8%]) based on patient reports. The proportion of patients with symptoms in different subgroups, as determined by sputum culture results and CXR findings is shown in Table 4. Patients reporting weight loss were more likely to have a positive sputum culture finding (7 of 12 patients [58%] vs 9 of 45 patients [20%], respectively; p = 0.025) [Table 4]. Univariate logistic regression analysis demonstrated that weight loss (odds ratio [OR], 5.6; 95% confidence interval [CI], 1.43 to 21.82; p = 0.013) and night sweats (OR, 7.2; 95% CI, 1.04 to 49.28; p = 0.045) were significantly associated with culture-positive sputum. In a multivariate analysis adjusted for radiographic findings and night sweats, only weight loss remained a significant variable with an OR of 4.3 (95% CI, 1.01 to 18.72; p = 0.049).

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Table 1—Patient Characteristics

Characteristics (n = 72) No. (%)
Age,t yr 42 (9-86)
Sex
Male 35 (49)
Female 37 (51)
Ethnicity/race
White 12 (17)
Black 19 (26)
Native American 3(4)
Hispanic 6(8)
Asian/Pacific Islander 32 (44)
Country of birth
United States 13(18)
Outside of United States 59 (82)
HIV status
Positive 5 (7)
Negative 52 (72)
Unknown 15 (21)
Primary sites of infection
LN ‘ 36 (51)
Pleura 12 (17)
CNS 6 (8)
GI 6 (8)
Bone and joint 4 (6)
Miliary TB 3 (4)
Others (GU and ear) 3 (4)
More than one site of disease! 2 (3)
Risk factors§
No identified risk factors 5 (7)
Foreign born 59 (82)
HIV infection 5 (7)
DM 6 (8)
Immunosuppression other than HIV and DM 4 (6)
Others: homelessness, alcohol, close contact to an infectious TB case 6 (8)

Table 2—CXR Findings Among 72 Extrapulmonary TB Patients

Disease Primary Sites CXRs (n = 72)
1Normal (n = 37) Abnormal(n = 35)
LNs (n = 36)
Extrathoracic 23 7
Intrathoracic 6
Pleura (n = 12) 12
CNS (n = 6)
Meningitis 3
Brain/epidural abscess 3
GI (n = 6) 1 5
Others (n = 10)
GU 2
Bone and joints 4
Miliary TB 3
Ear 1
More than one site of infection (n = 2)t 2

Table 3—Sputum Examinations and CXR Appearances of 57 XPTB Patients Based on the Primary Sites of Infection

Disease Primary Sites Positive Sputum Culture Result (n = 12) Negative Sputum Culture Result(n = 45)
INormal CXR Findings
(n = 5)
IAbnormal CXR Findings (n = 7) INormal CXR Findings (n = 22) IAbnormal CXR Findings
(n = 23)
LNs (n = 29)
Extrathoracic 2 16 4
Intrathoracic 1 6
Pleura (n = 10) 2 8
CNS (n = 5)
Meningitis 2 2
Brain/epidural abscess 1
GI (n = 4) 1 3
Others (n = 7)
GU 1
Bone and joints 3
Miliary TB 3
More than one site of infection 2
(n = 2)t

Table 4—The Association Among Sputum Culture for M tuberculosis, CXR Findings, and Clinical Symptoms

CXRs and Clinical Symptoms Sputum Examination Results (n = 57) p Valuef
Negative Culture Findings (n = 45) Positive Culture Findings (n = 12)
CXR findings
Normal 22 (81) 5(19)
Abnormal 8(80) 2 (20) NS
Respiratory symptoms
Cough 14 (32) 1 (8) NS
Constitutional symptoms!
Fever 10 (23) 5 (42) NS
Weakness/malaise 9(20) 2 (17) NS
Weight loss 9 (20) 7 (58) 0.025
Night sweat 2(4) 3 (25) NS
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