UNIVERSITY OF KHARTOUM Faculty of Medicine Postgraduate Medical Studies Board PATTERNS OF EXTRA-PULMONARY TUBERCULOSIS IN ADULT SUDANESE PATIENTS By Dr. Mohammed Osman Ahmed Minni M.B.B.S (University of Kassala) A thesis Submitted in partial fulfillment for the requirements of the Degree of Clinical MD in Medicine, April, 2004 Supervisor Prof. Abdel Gadir Mohammed Yousif Al kadaru FRCP-PhD, London 1 : ﻰﻟﺎﻌﺗ ﷲا لﺎﻗ ( ) ﺎًﻤﻠﻋ ﻲﻧدز ﻲﺑر ﻞﻗو ﻢﻴﻈﻌﻟا ﷲا قﺪﺻ 2 To my parents 3 I would like to express my sincere thanks and gratitude to my supervisor Prof. Abdel Gadir Mohammed Yousif Alkadaru, Dean of Faculty of Medicine University of Khartoum, for his meticulous supervision, continuous guidance, encouragement and for his very valuable advice throughout all stages of the study. Also I would like to record my heart full thanks to my colleagues Dr. Rashida, Dr. Amani, Dr. Tahani and Dr. Amal who helped me in data collection. Sincere thanks to my colleague Dr. Marwa Ismail who supplied me with some of the literature. I am also grateful for Mr. Hassan Ali for data analysis and Miss Widad A/Magsood for typing the thesis. 4 ABBREVIATIONS Abbreviation Meaning 99TC-MDP 99Technitium-methylene diphosphonate AD Adenosine deaminase ARI Average risk of infection BC Before christ BCG Bacillus Calmette Guerin C.T Computed Tomography CNS Central nervous system CSF Cerebrospinal fluid CXR Chest X-ray DOTs Directly observed treatments ECG Electrocardiogram EEG Electroencephalogram 5 ESR Erythrocyte sedimentation rate EX. Pul-TB Extra-pulmonary tuberculosis FMOH Federal Ministry of Health FNA Fine needle aspiration GIT Gastrointestinal tract HIV Human immunodefiency virus IFN Interferon INH Isoniazid IUAT-LD International Union Against Tuberculosis and Lung Disease MTB Mycobaecterium tuberculosis NTP National Tuberculosis Program PCR Polymerase chain reaction PDD Purified protein derivitives PZH Pyrazinamid S1 Sacroiliac joint TB Tuberculosis US Ultrasound WHO World Health Organization 6 ABSTRACT Tuberculosis is found worldwide, but it is particularly common in Africa and Asia. The prevalence of tuberculosis increases with poor social conditions, inadequate nutrition and over crowding. The impact of tuberculosis in the developing world has been magnified in the past 20 years by the emergence of HIV pandemic(10). This study is carried out as trial to evaluate the clinical presentations of extra pulmonary tuberculosis, to 7 assess methods used in the diagnosis, and to identify factors that may predispose to the disease. In this study 100 patients of different types of extra-pulmonary TB were enrolled. Abdominal TB was found to be the commonest (37%), followed by tuberculous lymphadenitis (20%). TB of the skeleton and that of the pleura accounted to (19%) and (9%) respectively, while CNS TB was found in (4%) of the study. Genitourinary, pericardial and miliary TB each was observed in (3%) of the cases. Cutaneous TB was the least encountered, occurring in only 2 of the 100 patients. Clinical manifestations generally depend on the organ involved in addition to the general symptoms such as fever, weight loss and night sweat. Ascites was the commonest presentation of abdominal TB whereas enlarged lymph nodes with or without sinus formation were the commonest presentation of tuberculous lymphadenitis. 8 Affection of the dorsal spine with or without kyphos formation was the remarkable feature of spinal TB. Pleural tuberculosis presented mainly with unilateral pleural effusion. Signs of space occupying lesion were the main mode of presentation of CNS tuberculosis as well as tuberculous meningitis. Pericardial tuberculosis presented with effusion in two patients while in one patient it presented with constrictive pericarditis. In most patients the diagnosis was made on clinical grounds in addition to the presence of a high ESR and a positive Mantoux test as well as other specific investigations such as ascitic, pleural, pericardial and cerebrospinal fluids analysis. Tissue histopathology was obtained in a minority of patients (38%) and in all of them it showed the specific features of tuberculosis. Most patients did not receive BCG vaccination. HIV screening test was done for 56 patients and it was positive in 18 of them. Pulmonary tuberculosis can co-exist although not commonly with extra-pulmonary TB and in fact 9 sputum for acid alcohol fast bacilli was positive in 4 of the enrolled cases. 10