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Lower-Lung-Field Tuberculosis in Saudi Arabia

1990; King Faisal Specialist Hospital and Research Centre; Volume: 10; Issue: 4 Linguagem: Inglês

10.5144/0256-4947.1990.374

0975-4466

Lalit Pandya, Nasser Al-Sharif, Ali Maraey, Abdulaziz Madani,

Mycobacterium research and diagnosis

Original ArticlesLower-Lung-Field Tuberculosis in Saudi Arabia Lalit Pandya, MSc, MD, MRCP (UK), MRCP (Ireland) Nasser Al-Sharif, MD, DTM&H (Liverpool), DTM (London) Ali Maraey, and MSc Abdulaziz MadaniMBBS Lalit Pandya Address reprint requests and correspondence to Dr. Pandya: Sahary Chest Hospital, P.O. Box 7966, Riyadh 11472, Saudi Arabia. From the Sahary Chest Hospital, Riyadh Search for more papers by this author , Nasser Al-Sharif From the Sahary Chest Hospital, Riyadh Search for more papers by this author , Ali Maraey From the Sahary Chest Hospital, Riyadh Search for more papers by this author , and Abdulaziz Madani From the Sahary Chest Hospital, Riyadh Search for more papers by this author Published Online:1 Jul 1990https://doi.org/10.5144/0256-4947.1990.374SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutAbstractOne hundred sixty-one patients were found to have lower-lung-field tuberculosis in a retrospective study of 1566 cases of pulmonary tuberculosis admitted to Sahary Chest Hospital, Riyadh. This represents 10.3% of the total admissions over a period of four years. Lower-lung-field tuberculosis is more common in females. Twenty-six percent of the patients had had previous antitubercular treatment. Sputum conversion took 40.4 days. Average hospital stay was 50 days. Hemoptysis was found in 46% of cases and diabetes mellitus was discovered in 13%. Chest x-ray studies showed right lung involvement in 46% of cases, bilateral involvement in 29%, and left lung involvement in 25% of cases. A cavitary lesion was found in 49%.IntroductionDespite improved living conditions, the establishment of extensive and efficient health care facilities, widespread bacillus Calmette-Guerin vaccination, and the implementation of preventive measures, pulmonary tuberculosis is still prevalent in the Kingdom of Saudi Arabia.1,2 A large number of tubercular patients present with extensive involvement of the lung. The clinical presentation of lower-lung-field tuberculosis (LLFT) in general practice often causes confusion. This may delay diagnosis because other diseases such as atypical pneumonia, classic pneumonia, and aspiration pneumonia present similar symptoms.LLFT is not uncommon. The first description was published in 1886 by Kidd.3 In 1888, Fowler reported the vulnerability of the apex of the lower lobe. After the advent of roentgenograms in the diagnosis of pulmonary tuberculosis, many reports became available.3-5 No studies on the prevalence of LLFT have been conducted in Saudi Arabia. We present our findings on LLFT–its clinical features, acid-fast bacilli (AFB) status, radiological features, and outcome of the therapy–obtained from both Saudi and non-Saudi patients.MATERIAL AND METHODSWe obtained the clinical notes and chest x-ray studies of all patients with pulmonary tuberculosis who were admitted to the Sahary Chest Hospital in Riyadh during July 1983 to August 1987 (1404 to 1407H). The diagnosis of pulmonary tuberculosis was based on positive sputum examination for AFB, positive tuberculin test, and characteristic findings on chest x-ray studies (i.e., lung involvement on a posteroanterior chest film that extends below an imaginary horizontal line across the hila and including parahilar regions).3 The following information was obtained from medical records: patient age, sex, nationality, presenting symptoms, past history, chest x-ray study, laboratory notes on sputum examination for AFB, length of hospital stay, and timing of sputum conversion.RESULTSLLFT was diagnosed in 161 of 1566 (10.3%) patients. There were 84 Saudi (52.2%) and 77 (47.8%) non-Saudi patients. There were 110 (68.3%) males and 51 (31.7%) females. The incidence of LLFT among female patients was statistically significant at P < 0.02. Among Saudi patients, there were 47 (55.9%) males and 37 (44.1%) females. Average age of males was 34.9 years and of females, 32.4 years. Table 1 gives a breakdown of different nationalities. Average hospital stay was 49.75 days. There were 119 (74%) new cases, and 42 (26%) cases in which there was a previous history of tuberculosis. Twenty-one patients left the hospital against medical advise or transferred to other hospitals. Two patients died during the period.Table 1. Distribution of cases of lower-lung-field tuberculosis in 161 patients.Table 1. Distribution of cases of lower-lung-field tuberculosis in 161 patients.One hundred and thirty-five (83.8%) patients had sputum that was positive for AFB on admission. Of these, 21 patients left the hospital against advice or transferred to another hospital, and one patient died. In the remaining 113 patients with positive sputum, 112 converted to negative after an average of 40.4 days. The most common symptom was cough, with or without expectoration, and was found in 158 patients (98.1%). General systemic symptoms were seen in 118 (73.3%) and hemoptysis in 74 (45.9%).Diabetes mellitus was found in 21 (13.0%) cases; other associated diseases were: lymph-adenopathy in five (3.1%), uremia in two (1.2%), epilepsy in one, and peritonitis in one. Three patients were pregnant. The right lung was noted to be involved more frequently than the left. Results of chest x-ray studies are shown in Table 2.Table 2. Site of lesion.Table 2. Site of lesion.DISCUSSIONPost-primary LLFT is not uncommon in the population of countries where tuberculosis is prevalent, but the reported incidence varies greatly, from 0.003% reported by Colton in 1923 to 18.3% cited by Ross in 1930.4 In two more recent reviews, a 0.85% incidence was reported from America3 and an incidence of 5.1% was reported from Taiwan.5 This great variation may be due to the use of different terms and definitions to identify the involvement of lower lung fields, such as “basal tuberculosis,” “lower lobe tuberculosis,” “hilar tuberculosis,” and “parahilar tuberculosis.”In all reports there is clear-cut evidence of a female preponderance.13 Chang et al5 in 1987 reported that 16.3% of the female tubercular patients had LLFT, which was five times greater than the percentage observed for males. The male to female ratio in our study was 1 to 1.5, which contradicts previously reported figures.3,5 The factors which predispose females to LLFT are not well understood. The average age of male and female patients is less, compared to the whole group of patients with pulmonary tuberculosis.6 Saudi nationals constituted about 52% of the total cases, which is not much different (49%) from the total number of Saudi patients in the whole group with pulmonary tuberculosis.6 The remaining nationalities represented from 1 to 14.3% of the patients. It has been reported that race and ethnic background play no part in the occurrence of LLFT.7The symptoms of LLFT do not differ from those in patients with pulmonary tuberculosis. Cough with or without expectoration was found in 98.1 % of cases, which is similar to the findings reported by Ramachandra et al4 (greater than 95%), Segarra3 (89%), and Vishwanathan (“main symptom”).8 General toxic symptoms were found in 73.3% of the cases, which is similar to that reported elsewhere.9,10 Hemoptysis occurred in 46% of the cases. Various other reports show a frequency of hemoptysis in LLFT that ranges from l.l%8 to 80%.11Seventy-four percent of our patients represent new cases. This agrees with the 75% reported by Pandya et al6 and implies that LLFT occurs sporadically among patients with pulmonary tuberculosis.There was a high percentage of sputum positiv-ity (84%) among patients with LLFT, compared to all cases of pulmonary tuberculosis (75%), and this was statistically significant atP < 0.02. The average time for sputum conversion was 40.4 days, which is close to that observed in pulmonary tuberculosis patients (42 days).6 This confirms the effectiveness of the standard four drugs (i.e., rifampicin, isoniazid, streptomycin, and pyrazinamide) in the treatment of LLFT. This agrees with the observations of Ramachandra et al4 and suggests that the poor results of treatment reported by earlier workers may be due to mechanical factors and the use of weak antituber-cular drugs.10A high incidence of diabetes mellitus in LLFT has been reported in the literature12 and an increased incidence was also observed in our series. Thirteen percent of the patients had diabetes compared to 8.7% out of the total 1566 patients with pulmonary tuberculosis studied from our hospital.13 This achieved statistical significance at P < 0.02. The incidence of LLFT in diabetic patients was 19.1% compared to 9.5% in nondiabetic patients, and this was statistically significant at P < 0.01. The reasons for this association are unknown.Bilateral involvement of the lower fields is found in 28.8% of cases, which is higher than that reported by Segarra et al3 (16%) and Ramachandra et al4 (21.8%). Right lung involvement was found in 46.6% of our cases, whereas Segarra reported 58% and Ramachandra cited 51.3% for this finding. Left lung involvement was seen in 24.8% of our patients, which is less than that reported in other reports,3,4 but the difference was not statistically significant. In cases of pulmonary tuberculosis as a whole, bilateral involvement has been observed in 46%, right lung involvement in 25.2%, and left lung involvement in 20.8%,6 but an opposite trend is observed for LLFT. Although a high incidence of right lower field involvement has been reported, the reason for this predilection is not known. It also does not appear to favor either sex.The reported incidence of cavitary lesions in the lower lung field ranges from 20%5 to 90%.14 In our study, cavitary lesions were found in 49.1% of the cases, which resembles the figure reported for pulmonary tuberculosis patients.6 The incidence of lymphadenopathy in our patients was 3.1% versus 1.66% for all patients with pulmonary tuberculosis,6 but this difference was not statistically significant. The increased incidence of lymphadenopathy in African and Asian patients is well known.15–17 It is possible that perforation of a lymph node into the bronchial system with spillage of AFB into the lung parenchyma is responsible for LLFT. The role of endobronchial involvement in LLFT is reported to be high, ranging from 46% to 76.2%.1,3 This needs evaluation in our patient population.Pulmonary tuberculosis should be considered early in the diagnostic evaluation of patients with diabetes mellitus or lesions that respond poorly to antibiotics and who also exhibit lower zone shadows on chest x-ray studies. Repeated examination of sputum to detect AFB and bronchoscopy should be done early to detect LLFT, as early treatment with the newly introduced anti-tubercular drugs is very effective.ARTICLE REFERENCES:1. Shanks NJ, Khalifa I, Al-Kalai D. "Tuberculosis in Saudi Arabia" . Saudi Med J. 1983; 4(2):151–6. Google Scholar2. Froude JRL, Kingston M. "Extrapulmonary tuberculosis in Saudi Arabia: a review of 162 cases" . King Faisal Specialist Hosp Med J. 1982; 2(2):85–95. Google Scholar3. Segarra F, Sherman DS, Rodriguez-Aguero J. "Lower lung field tuberculosis" . Am Rev Respir Dis. 1963; 87:37–40. Google Scholar4. Ramachandra JN, Agrawal GN, Srivastava VK, Mukerji PK. "Lower lung field tuberculosis" . Indian J Tuberculosis. 1982; 29(3):168–72. Google Scholar5. Chang SC, Lee PY, Perng RP. "Lower lung field tuberculosis" . Chest. 1987; 91(2):230–2. Google Scholar6. Pandya L, Al-Sharif N, Madani A. "A review of 1566 cases of pulmonary tuberculosis admitted to Ministry of Health chest hospital in Riyadh" . Ann Saudi Med. 1988; 8(6):525A–6A. Google Scholar7. Busby JF. "Basal tuberculosis" . Am Rev Respir Dis. 1939; 40:692. Google Scholar8. Vishwanathan R. "Tuberculosis of the lower lobe" . Br Med J. 1936; 2:1300. Google Scholar9. Parmar MS. "Lower lung field tuberculosis" . Am Rev Respir Dis. 1967; 96:310–3. Google Scholar10. Mathur KC, Tanwar KL, Razdan JN. "Lower lung tuberculosis" . Ind J Chest Dis. 1974; 16:31. Google Scholar11. Hamilton CE, Fredd H. "Lower lobe tuberculosis: a review" . JAMA. 1935; 105:427. Google Scholar12. Rao KN, et al., eds. Tuberculosis in relation to diabetes. In: Textbook of tuberculosis, ed 2. India: Vikas Publishing House, 1986. Google Scholar13. El-Sakka M, Pandya L, Al-Sharif N, et al.. "Pulmonary tuberculosis in diabetic patients: a review of 136 patients" . Ann Saudi Med. 1988; 8(6):525A. Google Scholar14. Hawkins FS, Thomas GO. "Lower lobe tuberculosis" . Tubercle. 1946; 27:82–7. Google Scholar15. Kent DC, Schwartz R. "Hilar lymphadenopathy in tuberculosis" . Am Rev Respir Dis. 1967; 96:435–9. Google Scholar16. Lukomsky GI. Bronchology. St. Louis: Mosby, 1979;:73–85. Google Scholar17. Hampries MJ, Nun AJ, Bujield SP, et al.. "National survey of tuberculosis notification in England and Wales in 1983: characteristics of disease" . Tubercle. 1987; 68:19–32. Google Scholar Previous article Next article FiguresReferencesRelatedDetailsCited byPandya L, Al-Sharif N, Maraey A, Al-Majed S and El-Sakka M (2019) Pulmonary Tuberculosis in Diabetic Patients, Annals of Saudi Medicine , 11:3, (293-296), Online publication date: 1-May-1991.Nabi G (2019) Lower-Lung-Field Tuberculosis in Saudi Arabia, Annals of Saudi Medicine , 11:3, (355-355), Online publication date: 1-May-1991. Volume 10, Issue 4July 1990 Metrics History Accepted2 September 1989Published online1 July 1990 InformationCopyright © 1990, Annals of Saudi MedicinePDF download