March 24 is World TB Day, reminding us of the impact of tuberculosis worldwide. While pulmonary TB is the most common and deadliest form of the disease, extrapulmonary TB (EPTB) is becoming increasingly significant. EPTB can infect virtually any organ in the body and has a clinical presentation that is generally nonspecific, making diagnosis and treatment challenging. In India, EPTB is a significant problem, but there is still much to learn about the spread of TB bacteria from the lungs to other parts of the body and how these bacteria interact with specific organs. Efforts must be made to generate high-quality data through clinical trials to formulate guidelines for the diagnosis and treatment of all forms of EPTB. This may uncover that EPTB is a more substantial public health problem than currently believed. Clinicians from different specialties need to be brought together to formulate guidelines and increase awareness of EPTB. Finally, the head of uveitis services at the LV Prasad Eye Institute in Hyderabad, India, provides expert care and treatment for patients with uveitis, a condition that can often be misdiagnosed as EPTB.
The Importance of Addressing Extrapulmonary TB in India
March 24 marks World TB Day, a day dedicated to raising awareness of a disease that has been impacting individuals for centuries. Tuberculosis (TB) is caused by the bacillus Mycobacterium tuberculosis, which spreads when an infected individual expels the bacteria through the mouth or nose. Despite advancements in treatment, TB continues to claim the lives of nearly 1.6 million individuals each year across the globe, with India alone accounting for over 25% of the TB burden.
While TB is commonly known as a pulmonary disease, it can also manifest as extrapulmonary TB (EPTB). EPTB accounts for 15-20% of all reported TB cases, and can infect virtually every organ in the body. When the bacillus affects other parts of the body, it enters the bloodstream from the lungs and spreads to different organs. These organs may harbor dormant bacteria or incite an inflammatory response that results in organ-specific symptoms.
Lymph nodes are one of the most commonly affected organs, accounting for roughly a third of all EPTB cases. They are an important component of our immune system that filter out pathogens from the body. Infection of the lymph nodes typically results in swelling and pain in the affected area. However, TB can also affect other organs such as the brain, gut, and eyes, resulting in neurological, gastrointestinal, or ocular symptoms.
Despite the severity and prevalence of EPTB, most TB research and government policies remain focused on pulmonary TB. However, it is crucial to address EPTB to effectively combat the disease. In India, EPTB accounts for approximately 50% of all TB cases in patients with HIV. To eliminate TB, it is important to shift focus to include EPTB in research and policy efforts.
In conclusion, TB continues to pose a significant threat to public health across the globe, with India bearing a large burden of the disease. While pulmonary TB is the most commonly known manifestation of the disease, EPTB accounts for a significant portion of TB cases and can affect various organs in the body. To effectively combat TB, it is crucial to address EPTB in research and policy efforts.
Challenges in Diagnosing and Treating Extrapulmonary TB
Diagnosing and treating extrapulmonary TB (EPTB) poses several challenges to clinicians due to the diverse scope of active infection. Clinical presentations of EPTB are often non-specific and can be mistaken for other infectious or non-infectious conditions. Additionally, detecting the bacteria in tissues is not as easy as it is in sputum samples of patients with lung TB, making diagnosis difficult.
More than half of patients with EPTB may not have associated lung disease, leading to a significant number of undiagnosed or late-diagnosed cases. Misdiagnosis can result in irreparable damage to organs, as is the case with TB of the eye, which is often misdiagnosed as uveitis, leading to prolonged vision loss for the patient.
One major challenge in addressing EPTB is the lack of awareness among physicians who may be treating EPTB cases in their clinics without adequate knowledge of the condition or the protocols to follow. Bringing together physicians from different specialties to discuss EPTB as a single entity is crucial to developing accurate diagnostic and treatment criteria. Specialists tend to remain confined to their own specialties, which limits their exposure to insights gained by other specialties in diagnosing and managing EPTB.
In conclusion, diagnosing and treating EPTB presents unique challenges due to the diverse range of active infection and non-specific clinical presentations. Raising awareness among physicians and bringing together specialists from different fields is necessary to effectively combat EPTB.
Addressing Extrapulmonary TB in India: The Need for Comprehensive Guidelines
In 2014, the Central TB Division of the government of India brought together TB experts from 10 different medical specialties to formulate guidelines for extrapulmonary TB (EPTB) in India. After nearly two years of work, the INDEX-TB (Indian Extrapulmonary TB) guidelines were produced, with select recommendations for five of the ten organ systems investigated. These guidelines were endorsed by the World Health Organisation (WHO) and helped to bring together different medical specialties on a common platform to highlight the cause of EPTB.
However, there is still much to be done by the central TB division and other inter-governmental agencies like the WHO to address EPTB comprehensively. One important step would be to collect data on the prevalence of EPTB in the community from different medical specialties, rather than relying solely on TB departments in large hospitals. The government of India runs the Ni-Kshay program, a web-enabled patient management system for TB control, which allows health professionals from both public and private sectors to register TB cases under their care and access TB-related facilities. However, the program suffers from incomplete information, and many TB patients are not notified in the Ni-Kshay database. Additionally, many cases of EPTB remain undiagnosed and patients are often unaware of the condition.
To address these challenges, it is important to proactively screen patients presenting with different extrapulmonary symptoms in both public and private healthcare for evidence of EPTB. Generating high-quality data through clinical trials is also crucial for formulating guidelines for the diagnosis and treatment of all forms of EPTB. Currently, the mechanisms of the spread of TB bacteria from the lungs to other parts of the body, and how these bacteria interact with specific organs in the body are not well understood.
Addressing these issues can help uncover the true extent of EPTB as a public health problem and enable the identification of patients with EPTB across the country, providing them with access to appropriate care. It is imperative that the central TB division and other inter-governmental agencies take proactive steps to address EPTB comprehensively.
In conclusion, while the INDEX-TB guidelines were a good start to addressing EPTB in India, much more needs to be done to generate high-quality data and comprehensive guidelines for the diagnosis and treatment of all forms of EPTB. Proactively screening patients and collecting data from different medical specialties can help uncover the true extent of EPTB as a public health problem and enable the provision of appropriate care to patients with EPTB.
Expert Uveitis Services at LV Prasad Eye Institute
Soumyava Basu is the head of uveitis services at the LV Prasad Eye Institute in Hyderabad, India. The institute provides expert care and treatment for patients with uveitis, a condition that can often be misdiagnosed as extrapulmonary TB.
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