Tuberculosis:

Case Studies from Southern India

WEMJ Volume 112 No 3 Article 1 September 2013

Merryn Rhodes
July 2013 This report aims to increase the gen- Consent
Year 3 External Student Selected Component
eral knowledge of TB above the base- Verbal consent was gained from all pa-
University of Bristol MBChB tients before including their information
line taught in standard medical school
courses. By presenting 4 case studies a in this report. All cases have been fully
Introduction personal element will be added to the re- annoymised and identifying information
view, illustrating more clearly the nature removed.
Tuberculosis (TB) is one of the oldest and treatment of TB. The histories dis-
A note on photographs of X-rays
illnesses known to man, plaguing popu- cussed here will cover the topics of typi- Photographs of chest x-rays have been included in
lations for centuries and claiming the cal presentation, medical complications, this report to enhance understanding. However due
lives of many notable historical figures. drug-resistance and HIV co-infection. to confidentiality limiting access to the system I was
Despite the availability of a cheap and only permitted to take photographs from the com-
puter screens, unfortunately resulting in fairly low
effective cure for over 70 years, TB still Method quality images.
presents a significant global burden. In
1993 TB was declared a worldwide pub- With 2-2.5 million new cases in 2011, Case 1: Ms N
lic health emergency, and the subsequent India has the highest incidence of TB
WHO strategy has been experiencing in the world,[2] making it an ideal loca- Ms N presented to outpatient clinic fol-
great success in reducing mortality from tion for the study of the disease and the lowing a 2-month history of cough with
the disease.[1] However, the emergence of acquisition of a wide-range of cases. expectoration and a low-grade fever in
obstacles such as drug-resistance and the The Christian Medical College (CMC) the evenings. She also noted several
HIV epidemic mean that TB remains a in Vellore, South India, is one of the top episodes of haemoptysis within this time
major world killer, with 8.7 million new medical institutions in India and cares period, and was experiencing right sided
cases and 1.4 million deaths reported in for over 8,000 patients daily.[5] chest pain. A chest x-ray and CT taken
2011.[2] at a community hospital revealed a right
sided pleural effusion.
Infection with Mycobacterium tu-
berculosis does not usually present a On hearing her history Ms N’s doctor
problem to a healthy individual, whose immediately ensured that facemasks
immune system should be capable of were worn by all medical staff and sug-
eliminating, or at least containing, the gested that the patient do so as well. He
disease. In the latter cases TB is held in a explained to the patient that his imme-
dormant, non-infectious, state within the diate concern was of TB and he would
body, but the individual is at risk of de- need to analyse Ms N’s sputum, take an-
veloping active disease should their im- other chest x-ray and do a pleural biopsy.
mune system weaken. TB is a disease of Figure 1a: The main entrance to CMC, Vellore A follow-up appointment was arranged
the ill and the poor, as they are less capa- for 5 days later to discuss these results.
ble of building a strong immune defence. I was offered a 2-week Clinical Observer
Because of this the highest incidence of posting at CMC in July. Here I was Ms N’s sputum was positive for acid-
TB is in developing countries, with India able to observe outpatient clinics, ward fast bacilli and Xpert MTB/RIF analysis
and China accounting for 26% and 12% rounds and team meetings, and through revealed the presence of TB with no
of global incident cases respective,[2] yet this experience I met and talked with resistance. Her pleural biopsy showed
it is not unknown to the West. In Eu- patients with TB, learning about their granulomatous inflammation whilst her
rope TB is responsible for the deaths of histories and treatment chest x-ray was inconclusive. She was
7 people every hour,[3] with increasing
immigration from high-burden countries Figure 1b: Busy outpatients department
continually bringing new cases. In the
UK case incidence was not insignificant
at 8963 in 2011, a population rate of 14.4
per 100,000.[4] The majority of cases are
reported in major cities with high immi-
gration rates, and with the compounding
factors of inadequate housing and poor
healthcare in many migrant communi-
ties, it is not unlikely for many Western
physicians to encounter the disease.
 Tuberculosis:
Case Studies from Southern India
WEMJ Volume 112 No 3 Article 1 September 2013

consequentially commenced on anti- Ms N’s should spark a similar response. Following the above results Mr K was
tubercular treatment under management These include immunocompromised admitted for intercostal drain insertion
of the DOTS clinic. patients, those with chronic illness or to drain the hydropneumothorax. This
Ms N’s case provides us with an ex- malnutrition, migrants from TB-endemic was successful, however he developed
ample of what an initial presentation of countries, and individuals living in poor a grade 1 bronchopleural fistula and
pulmonary TB can look like. A ‘typi- quality, crowded accommodation.[6] If low-grade fever, and therefore remained
cal’ case of pulmonary TB presents with TB is not considered in these patients in hospital for management. This im-
chronic cough, haemoptysis, weight loss, then not only will they not be given pacted heavily on his studies and he was
intermittent fever, night sweats, reduced effective treatment, but also they will required to take further time out of his
appetite and sputum production[6],[7]. The remain infectious. Therefore keeping Ms course.
clinical picture can vary widely, how- N in mind may help to identify these un-
ever, and the presence of any one of 4 common cases earlier on, and save many The case of Mr K highlights several
symptoms (weight loss, night sweats, fe- lives in the process. factors. Firstly, in India TB is not solely
ver or cough) has been shown to be 80% a disease of the old or chronically ill: it
sensitive in warranting further investiga- Case 2: Mr K can have a devastating impact upon the
tion.[8] young and healthy too. Secondly, despite
Mr K is a 19-year-old student. He was adequate treatment complications can
When concerned about TB, diagnosis referred by a private clinic to the CMC still develop. This can have a large im-
is typically made using sputum smear following a three-week history of severe pact upon the patient’s life and, as for Mr
microscopy. Two samples are tested over breathlessness at rest. Two months pre- K, it is important to maintain close fol-
two consecutive days and stained using viously Mr K had been diagnosed with low-up of TB patients – a point of great
the Ziehl-Neelson method, after which pulmonary TB by an outside facility due difficulty in many developing countries.
the patient can be classified as ‘sputum- to a six-week history of low-grade fever
positive’ or ‘sputum-negative’ .[9] Further and cough with expectoration. He had Treating TB is a lengthy process. Mr
analysis using Xpert MTB/RIF, a rapid, then been commenced on first line anti- K’s first-line therapy would have been a
cartridge-based assay, can provide de- tubercular treatment, following which his 6-month course of 4 antibiotics (rifampi-
tection of TB within two hours, as well symptoms improved. cin, ethambutol, isoniazid and pyrazin-
as identifying rifampicin resistance.[10] amide), most likely taken thrice weekly.
The WHO has recommended the use of On examination Mr K was hypotensive If this standard course is not closely
Xpert since 2010, and it is currently the (90/60 mmHg); tachycardic (108 BPM); complied with and completed then drug
subject of a three-year global rollout pro- tachypnoeic (26 RPM); and had de- resistance can emerge,[13] as well as re-
gramme, costing $25.9 million (US).[10] creased breath sounds with crepitations lapse or further complications of the dis-
audible on the right side. ease (see below). It usually takes around
Chest x-rays are routinely taken, but as 2 weeks for non-resistant sputum-posi-
seen in the case of Ms N they can lack Mr K’s sputum stain showed acid-fast tive pulmonary TB patients to stop be-
sensitivity and specificity, and therefore bacilli and further Xpert MTB/RIF ing infectious, and at least 6 months to
should not be relied on solely for diag- analysis revealed the presence of non-re- ensure all the bacteria are killed.[6] This
nosis. However, studies evaluating the sistant TB. Chest x-ray showed a hydro- treatment incurs a large cost to Indian
control of TB in India have identified an pneumothorax (see below). patients even if their medication is subsi-
over-reliance on x-rays for diagnosis, re- Figure 2. dised, due to the working time lost dur-
sulting in under-detection of active cases. Mr K’s chest x-ray taken on admission dis- ing the illness period. Total cost has been
plays a right-sided hydropneumothorax:
[11] Therefore the WHO endorses diagno- estimated to represent 193% of a manual
sis through bacteriology: providing case- labourers’ monthly income,[14] although
detection through smear microscopy is this will vary from state-to-state. Com-
one of the five elements of DOTS, the paratively the UK views TB treatment as
treatment principle at the heart of the relatively inexpensive if uncomplicated,
WHO’s Stop TB Policy .[12] but this cost can rise by over 25 times in
complex or drug-resistant cases: [15] fur-
Ms N’s case also illustrates the scale of ther motivation for stringent monitoring.
the epidemic in India. Her presenting
history would not have sparked such Unfortunately TB is a burden in pre-
immediate concern for TB in a Western cisely the countries where receiving and
country, highlighting the frequency at complying with this sort of treatment
which Indian physicians see the disease. protocol is problematic. Poor infrastruc-
However, even in countries where TB ture, poverty and lack of information
is rare, there are particular patient sub- make access to medication difficult for
groups for which presentations such as many, inspiring the WHO to develop
 Tuberculosis:
Case Studies from Southern India
WEMJ Volume 112 No 3 Article 1 September 2013

the DOTS strategy.[16] This is an effec- sively drug-resistant strain of TB: resis- tively low, with the more severe exten-
tive policy, with the Indian National TB tant to isoniazid, ofloxacin, rifampicin, sively drug-resistant (XDR-TB) cases
Programme (RNTCP) reporting a cure ethoniamide, streptomycin, capreokycin - such as Mr D - accounting for a very
rate of over 85% in new sputum posi- and ethambutol, but susceptible to kana- small proportion.[11],[27] MDR-TB, with
tive patients since using a DOTS-based mycin. it’s lengthened infectious period and
strategy.[11] Therefore all treatment of TB complicated treatment regimen,[6] pres-
patients should comply with DOTS pro- Mr D was admitted to the isolation ward ents a significant obstacle to TB control
tocols, and physicians should be familiar and began an extensive regimen of sec- worldwide. It is estimated that only 10%
with these when managing the illness. ond line anti-tubercular drugs. Despite of cases of MDR-TB are currently being
subsequent discharge to DOTS clinic, diagnosed, and only half of these receive
Mr K is by no means unusual in de- Mr D has been frequently re-admitted the appropriate treatment. [13] Therefore
veloping a hydropneumothorax. Both to manage complications. He appeared the WHO recommends that all patients
pneumothoraces and pleural effusions tired although generally well in clinic, receive rapid drug susceptibility testing
are frequently observed complications and is currently being treated daily with when diagnosed:[28] a much-needed step
of pulmonary TB,[17] and destruction amikacin, cycloserine, moxifloxacin and to reduce MDR-TB, presupposing it is
and scarring of lung tissue can also kanamycin. Mr D has a sputum smear followed.
cause long-term conditions such as test 3 days every month, as well as a spu-
bronchiectasis and recurrent pneumo- tum culture every 3 months to check for The causes of MDR-TB are multifacto-
nia.[18] Furthermore, the influence of sensitivity. He also has frequent follow- rial. Genetic mutations occur when the
TB is not necessarily confined to the up chest x-rays, with one series reveal- bacilli replicate, and these can make the
lungs. Amongst the myriad systemic ing a massive left-sided pleural effusion bacteria resistant to certain medication.
complications of TB are hyponatra- and inadequate lung expansion following When the drug regimen is poorly or in-
emia, syndrome of inappropriate ADH drainage: complications of his long-term adequately administered these bacilli can
secretion,[19] altered mental state, haema- disease. become dominant in the strain, causing
tological abnormalities,[20] tuberculous resistant TB.[27]
meningitis,[21] arthritis,[6] abdominal and
pelvic inflammatory disease, [22] and
lymphadenopathy.

Whilst thankfully not occurring in Mr

K, extra-pulmonary tuberculosis can
either be a complication of poorly treated
pulmonary infection, or in fact be the
primary infection. Whilst much less
infectious than pulmonary strains, it can
be tricky to diagnose with the milieu of
symptoms often presenting a confusing
picture. Furthermore, extra pulmonary
TB occurs in between 10 and 42% of TB
patients, depending on background,[23]
and thus may be the answer to a patient’s
otherwise unexplained symptoms. [24]

Case 3: Mr D
Figure 3a Figure 3b
Mr D was seen in an outpatient clinic, Chest x-ray showing Mr D’s large left sided Mr D’s Chest x-ray following drain inser-
having initially presented 2 years ago pleural effusion: tion shows inadequate recovery:
with productive cough, haemoptysis and
low-grade fever. He was diagnosed with Factors that can lead to a regimen being
TB, with further analyses revealing the Multi-drug resistant tuberculosis (MDR- inadequate include, but are not limited
strain to be resistant to both isoniazid TB) is defined as a strain of TB that to: non-compliance with guidelines;
and rifampicin. He was placed on sec- is resistant to elimination by isoniazid poorly monitored treatment; incorrect
ond line anti-tubercular treatment and and rifampicin, 2 of the most powerful dosages or drugs used; poor quality and
managed by a private clinic, and as such first-line drugs.[25] Globally MDR-TB is availability of medication; poor adher-
the exact details of his treatment are estimated to account for 3.7% (650,000) ence to therapy course and lack of infor-
unknown. He was later referred to CMC [26] of new cases and 20% of those mation regarding the risks.[27] A variety
with recurrence of his original symp- previously treated.[2] Fortunately the of socio-economic factors contribute to
toms. He was revealed to have an exten- incidence of MDR-TB in India is rela- this, and whilst DOT acts to tackle these,
 Tuberculosis:
Case Studies from Southern India
WEMJ Volume 112 No 3 Article 1 September 2013

they are still presenting a barrier to TB Case 4: Mr F and multiple enlarged lymph nodes (on
elimination. If inadequate drugs con- abdominal ultrasound). LFTs were not
tinue to be used in an MDR-TB patient Mr F was a 43-year-old unemployed deranged.
this can create further resistance in the male with a standing diagnosis of HIV
strain. This is a possible cause of Mr D’s (WHO Classification Stage 4). He pre- A diagnosis of disseminated TB with
XDR-TB, and a problematic outcome of sented to outpatients with a 2-month his- concurrent HIV infection was made,
a fractured public/private medical sys- tory of low-grade fever and cough with and Mr F was started on first line anti-
tem, highlighting the necessity of closely expectoration. For the 2 days prior to tubercular treatment as an inpatient. Due
adhering to treatment guidelines. presentation his fever had increased and to the development of a rifampicin in-
he was experiencing intermittent chills duced cholestasis Mr F’s rifampicin was
As can be seen by Mr D’s history, the and rigors, mild dyspnoea and a ‘dull, stopped and he was started on levofloxa-
treatment of MDR-TB is complex and aching’ abdominal pain with disten- cin. He was also treated prophylactically
prolonged. The WHO’s 2011 revised sion. He had a history of chronic alcohol with azithromycin due to his low CD4
guidelines suggest a combination of no abuse and a 7-pack year history of ciga- count. His condition improved over 8
less than 5 drugs, including an injectable, rette smoking. days and he was discharged to outpatient
to be administered daily for a period of care.
at least 8 months, followed by a further Examination found palpable left axial,
12-20 months of tailored treatment.[28] left supraclavicular and left posterior Mr F’s chest x-ray taken 2 days after
This cocktail should include the first-line cervical lymph nodes. He was febrile at admission showed a disseminated pattern
drug pyrazinamide, which may cause 101°F and tachypneic with a respiratory of TB infection (see figure 4).
hepatotoxicity; a fluroquinolone that rate of 25.
risks GI and neurological disturbances; Globally 13% of all TB patients are HIV
cycloserine, commonly causing CNS Investigations revealed pancytopaenia positive, with a vast majority (79%) of
effects such as paranoia and psychosis; (Hb 6.0gdL; WBC 3.5 x109/L; Platelets these individuals living in African coun-
ethionamide, frequently resulting in nau- <130 x109/L); a decreased CD4 count tries.[2] Though in India HIV co-infection
sea and vomiting; and a parenteral amin- (11%); granulomatous inflammation occurs in only 5% of all cases, in ab-
oglycoside, risking renal impairment and of pleura and bone marrow on biopsy solute figures this is nearly 10% of the
irreversible ototoxicity.[28] Simply the (consistent with TB); the presence of worldwide burden [11]: further indicating
concept of this medication regime is off non-resistant TB in sputum and bone the scale of the Indian epidemic.
putting, let alone the practice of adhering marrow by Xpert MTB/RIF analysis;
to it for up to 20 months: it is easy to see In having HIV, Mr F’s immune system
how difficulties can arise in MDR-TB Figure 4: Mr F’s Chest x-ray showing a had been drastically weakened, reduc-
nodular pattern of disseminated tuberculosis
therapy. However, these recommenda-
tions do not necessarily apply to Mr D’s
strain of TB as there is a lack of evidence
available on XDR-TB treatment[28]. Due
to this, XDR-TB patients are likely to
have further drugs added to their regi-
men, and a substantially increased treat-
ment period[28], complicating matters
even further.

Despite this there is good news coming

in from research in TB pharmacology.
For the first time in 5 decades new drugs
have been developed and are expected to
be effective against MDR-TB, providing
a shorter and better-tolerated treatment
regimen, with a lower pill-burden.[26]
Some of these medications are predicted
to be available soon - late in 2013[29] -
and so physicians need to keep abreast
of these developments to ensure the best
possible care, and reduce the risk of
cases like Mr D’s.
 Tuberculosis:
Case Studies from Southern India
WEMJ Volume 112 No 3 Article 1 September 2013

ing his ability to fight and contain infec- ever, in this case Mr F’s chronic alcohol of the numerous complications and ob-
tion by tuberculosis mycobacteria. Such abuse would have excluded him from stacles involved in treatment. This report
individuals have increased susceptibil- receiving this treatment, as the combina- describes four case histories of TB, each
ity not only to new infection with TB, tion incurs a high risk of hepatoxicity.[37] highlighting a different aspect of the
but also re-activation of latent bacteria. Other inclusion criteria, such as avail- disease and expanding our knowledge
Considering that one-third of the world’s ability to follow-up and good HIV/TB of effective management. Awareness
population is postulated to have latent programmes, must also be met to provide of TB presentation and at-risk patient
TB,[6] this is not an insignificant risk. preventative therapy. [37] groups is necessary for quick and accu-
rate diagnosis, helping to reduce mortal-
HIV and TB are a deadly combination. Prophylaxis for opportunistic infections ity, morbidity and abate the spread of
TB increases the rate of HIV replication in HIV-TB patients is available through the infection. Further consideration of
and progression of infection, whilst HIV the use of cotrimoxazole, a broad-spec- the possible complications and co-mor-
reduces the body’s capability to fight trum antibiotic. It is a well-tolerated and bidities that can arise over the lengthy
the infection, dramatically increasing cost-effective medication with a strong course of treatment is necessary, as they
morbidity and mortality [30],[31]. Mr F’s evidence base in reducing hospitalisa- are not uncommon and may considerably
history makes this point clearly, with the tion and mortality.[31] However, studies compound the affect of disease upon the
infection spreading to his bone marrow in India have shown limited efficacy, patient’s life. Close adherence to pub-
and disseminating throughout his chest despite the drug being freely available lished treatment protocols is essential
and abdomen. This synergy has led to at chemists, due to poor adherence and as drug-resistance can emerge, bringing
TB being labelled as the leading cause of inadequate ART administration.[38] Thus with it increased morbidity and a vastly
AIDS-related death worldwide.[32] the routine inclusion of cotrimaxazole convoluted treatment regimen. Finally,
as part of ART for HIV-TB patients is the lethal synergy of HIV and TB means
Rapid treatment for HIV-TB is essential strongly recommended,[31] but this will that co-infection must be consistently
in stopping these preventable deaths. rely upon the presence of good HIV pro- considered and actively prevented, with
Patients should be commenced on anti- grammes. treatment administered rapidly and effec-
retroviral therapy (ART) alongside The complex, deadly interactions of tively when it occurs. By keeping these
standard tuberculosis medications, with these two epidemics provide a great deal factors in mind doctors in every country,
studies showing that delaying ART can more for consideration than discussed regardless of the disease prevalence, can
increase mortality by up to 100%.[33],[34] here. Expanding on this knowledge and help face and eliminate the burden of
Recommendations currently state that collaborating closely with HIV and TB TB.
ART should be started within 8-weeks teams is essential for the effective sup- Reflection
of anti-tubercular treatment, and sooner port of cases such as Mr F. I have really valued and enjoyed my time
in those with very low CD4+ counts. working on this eSSC project. I feel very
[31],[35] Unfortunately the concomitant CONCLUSION lucky to have had the chance to witness
use of these two treatment protocols is Tuberculosis is a global killer. In order the treatment of TB, an important global
not without risk. Potential drug interac- to care for it’s victims and assist in its disease, in a country where it presents
tions complicate matters, with at least eradication physicians need to be aware such a problem.
10% of patients developing the immune
reconstitution inflammatory syndrome
(IRIS) after initiating joint treatment.[13]
IRIS is a paradoxical worsening of tuber-
culosis, and other infectious conditions,
following initiation of ART, and is more
common in patients with low CD4+
count.[36] Furthermore, first-line drug
rifampicin is an enzyme-inducer that will
reduce the serum concentrations of medi-
cations used in ART. As such, rifabutin,
a less-potent inducer, is recommended in
HIV-TB cases. However this will only
reduce, not remove, the influence. [26]

Considering the above it is worth bear-

ing in mind TB prophylaxis. A patient
such as Mr F could have be offered a
6-month course of isoniazid, as long he
Figure 5: Cluttered corridors at CMC
had no signs of active infection. How-
 Tuberculosis:
Case Studies from Southern India
WEMJ Volume 112 No 3 Article 1 September 2013

I can say without a doubt that the experi-

ence has drastically improved my knowl-
edge of the illness and I would hope that
I am much better equipped to manage
these cases. Furthermore the perspec-
tive I gained has made me take stock of
aspects of the English healthcare service
I have taken for granted, such as freedom
of access and dedication to patient pri-
vacy. Despite CMC having a very similar
structure to UK hospitals and access to
comparable medical therapies, I found
the care provided different in several
fundamental ways. Not nearly as much
importance was placed upon cleanli-
ness and patient privacy as it would
have been in the UK, and what struck
me most was the lack of working hand
washing facilities in the toilets – even
on the infectious diseases ward! Despite
this, the driven and committed attitude
of all of the staff - without exception -
Figure 6: Broken sinks in the patient’s toilet
was inspiring, and there was no doubt
that the patients felt safe and cared for in
their hands. I would like to emulate this information but was unable to delve into 3. Kuehne J & Finch K. Bridging The Gap:
any aspect in much detail, despite very Why the European Union must address the
attitude in my career and hope this may
much wanting to. Ideally I would have global fund’s funding crisis to tackle the
make my patients feel the same way.
produced a much larger, more in-depth escalating HIV and TB epidemics in Eastern
Europe and Central Asia, TB Europe Coali-
In having to find my way in a large, busy final result, and would certainly be in- tion. Position Paper. (September 2012)
foreign hospital I believe that I have terested in expanding upon what I have
4. Pedrazzoli D, Fulton N, Anderson L, et
further developed my ability for inde- gained here in the future. Furthermore I
al, Tuberculosis in the UK: 2012 Report,
pendent learning. This will be of incred- found it difficult to display a great deal Health Protection Agency. (5th July 2012)
ible use to me in Fourth Year, hopefully of original, critical thought whilst trying 5. Christian Medical College, Vellore. Facts
encouraging me to engage fully with the to fulfil the aims of my project. There- and Figures. Website Accessed via URL:
programme and actively gain experienc- fore, I feel I was unable to develop this http://www.cmch-vellore.edu/pdf/CMC-
es I may otherwise have been to timid to. aspect of my academic work as much as Year2012.pdf on 21/07/2013
As such I am very glad that I undertook I would have liked, and will be looking 6. National Institute for Health and Care
such a project for my Third Year SSC. to undertake a narrower brief for my next Excellence. (2011) Tuberculosis: Clinical
project in the hopes that I can rectify diagnosis and management of tuberculosis,
Furthermore, presenting case studies is
this. and measures for its prevention and control.
an important method of communication
(CG: 117). London: National Institute for
amongst the medical profession, and in Health and Care Excellence.
doing so I have improved and developed In conclusion, I have relished the oppor- 7. Lawn, SD, Zumla AI. Tuberculosis. Lan-
upon the skills I acquired in the Third tunity to learn about TB in such a first
cet. (2011). 278:57-72
Year Medicine and Surgery module. hand way, and have gleaned a great deal
8. Getahun H, Kittikraisak W, Heilig CM, et
This SSC gave me the opportunity to more from this than I would have in do- al. Development of a standardized screen-
gather new knowledge that does not sit ing a library project on this topic. ing rule for tuberculosis in people living
within the core curriculum of the medi- with HIV in resource-constrained settings:
cal course. In producing it in this manner References individual participant data meta-analysis of
– as an overview for a medical student observational studies. PLoSMed. (2011).
audience – I feel I made the most of this, 1. WHO, Global Health Observatory, Tuber- 8:1]
culosis, Website Accessed via URL: http:// 9. Revised National Tuberculosis Control
and hope that it would be useful for other
www.who.int/gho/tb/en/index.html/ on Programme. RNTCP At a Glance. Training
students to read.
24/07/2013 Module. Accessed via URL: http://www.
2. World Health Organisation. Global tuber- tbcindia.nic.in/pdfs/RNTCP%20at%20
Despite this, I feel slightly unfulfilled culosis report 2012. Geneva: World Health a%20Glance.pdf on 15/07/2013
with the final report I have produced. Organization. WHO/HTM/TB/2012.6 10. World Health Organisation. TB Xpert
In this project I gathered a wide span of (2012) Project. Information Leaflet. (2013). Ac-
 Tuberculosis:
Case Studies from Southern India
WEMJ Volume 112 No 3 Article 1 September 2013

cessed via URL: http://who.int/tb/fea- sis-a-challenging-problem/ on 22/07/2013 Africa. Guidelines for tuberculosis preven-
tures_archive/TBXpert_briefing_note.pdf 25. Iseman MD, Goble M. Multidrug-re- tative therapy among HIV infected individu-
on 24/07/2013 sistant tuberculosis. NEJM. (1996). 334(4): als in South Africa. (2010). Report issued
11. Directorate General of Health Services. 267 online. Accessed via URL http://www.who.
TB India 2012: Revised National Control 26. Zumla A, Nahid P, Cole ST. Advances in int/hiv/pub/guidelines/south_africa_hiv_
Programme Annual status report. (March the development of new tuberculosis drugs tb.pdf on 24/07/2013
2012). New Delhi: IG Printers Pvt. and treatment regimens. Nature Reviews 38. Raizada N, Chauban L, Babu B. Linking
12. World Health Organisation, Stop TB Drug Discovery. (2013). 12:388-404 HIV-Infected TB Patients to Cotrimoxazole
Partnership. The Stop TB Strategy: Build- 27. Directorate General of Health Services. Prophylaxis and Antiretroviral Treatment in
ing on and enhancing DOTS to meet the TB India 2012: Revised National Control India. PLoS One. (2009). 4(6):e5999
TB-related Millennium Development Goals. Programme: Guidelines on Programmatic
Geneva: World Health Organisation. WHO/ Management of Drug Resistant TB (PMDT)
HTM/TB/2006.368. (2006). in India (May 2012). New Delhi. Acknowledgments
13. Zumla A, Raviglione M, Hafner R, 28. World Health Organisation. Guide-
Fordham von Reyn C. Tuberculosis. NEJM. lines for the programmatic management of I would like to thank my supervisor Dr
(2013). 368:745-755 drug-resistant tuberculosis: 2011 Update.
Nabil Jarad, and Vice-Principal of the
14. John KR, Daley P, Kincler N et al, Cost Geneva: World Health Organisation. WHO/
CMC Dr Anna Pulimood, for their con-
incurred by patients with pulmonary tuber- HTM/TB/2011.6 (2011)
culosis in rural India. Int J Tuberc Lung Dis. 29. TB Europe Coalition. Multi-drug tinued support during my project. Further
(2009). 13(10):1281-7 Resistant Tuberculosis – No Promises. thanks go to Ms Sheela Jacob and all of
15. NHS, Tuberculosis, Accessed via URL: (2013). Online Information Video. Ac- the doctors on the Pulmonary Medicine
http://www.londonhp.nhs.uk/services/tuber- cessed via URL: http://www.tbcoalition. and Infectious Diseases teams at CMC,
culosis/ on 22/08/2013 eu/2013/07/18/2739/ on 22/07/2013 who assisted me daily during my place-
16. World Health Organisation. Treatment 30. Churchyard GJ, Kleinschmidt I, Cor- ment. Finally, this project would not
of tuberculosis guidelines: Fourth Edition. bett EL et al. Factors associated with an have been possible without the kindness
Geneva: World Health Organisation. WHO/ increased case-fatality rate in HIV-infected and willing of all the patients who shared
HTM/TB/2009.420 (2010) and non-infected South African gold miners their time, and their histories, with me,
17. Shamaei M, Taharsi P, Poihan S et al. with pulmonary tuberculosis. Int J Tuberc and for this I am incredibly grateful.
Tuberculosis-associated secondary pneu- Lung Dis. (2000) 4:705-12.
mothorax: a retrospective study of 53 pa- 31. World Health Organisation. WHO
tients. Respir Care. (2011). Mar: 56(3):298- policy on collaborative TB/HIV activities:
302 Guidelines for programmes and other stake-
18. Salkin D. Tuberculosis as a cause of up- holders. Geneva: World Health Organisa-
per lobe bronchiectasis. Calif Med. (1950). tion. WHO/HIV/2012.1 (2012)
73(6):577-580 32. TB Europe Coalition. TB-HIV Co-
19. Jafari NJ, Izadi M, Sarrafzadeh F et al. infection. Website accessed via URL: http://
Hyponatremia due to pulmonary tuberculo- www.tbcoalition.eu/what-is-tuberculosis/tb-
sis: review of 200 cases. Nephrourol Mon. hiv-co-infection/ on 22/07/2013
(2013). 5(1):687-691 33. Gandhi NR, Moll A, Sturm AW et al.
20. Sharma R, Acharya K, Poornima V. A Extensively drug-resistant tuberculosis
rare complication of pulmonary tuberculo- as a cause of death in patients co-infected
sis. JIACM. (2007). 8(2): 179-81 with tuberculosis and HIV in a rural area
21. Anderson NE. Somaratne J, Mason DF of South Africa. Lancet. (2006). 368: 1575-
et al. Neurological and systemic complica- 1580
tions of tuberculous meningitis and its treat- 34. Dheda K, Shean K, Zumla A. et al.
ment at Auckland City Hospital, New Zea- Early treatment outcomes and HIV status
land. J Clin Neurosci. (2010). 17(9):1114-8 of patients with extensively drug-resistant
22. Saaiq M, Shah SA, Zubair M. Abdomi- tuberculosis in South Africa: a retrospective
nal tuberculosis: epidemiologic profile and cohort study. Lancet. (2010). 375:1798-
management experience of 233 cases. J Pak 1807.
Med Assoc. (2012) 62(7):704-7 35. Havlir DV, Kendal MA, Ive P. et al.
23. Caws M, Thwaites G, Dunstan S et al. Timing of antiretroviral therapy for HIV-1
The influence of host and bacterial genotype infection and tuberculosis. NEJM. (2011).
on the development of disseminated disease 365:1482-1491.
with Mycobacterium tuberculosis. PLoS 36. Naidoo K, Yende-Zuma N, Padavtchi N
Pathog. (2008). 4(3).e1000034 et al. The immune reconstitution inflamma-
24. TB Europe Coalition. Extrapulmonary tory syndrome after antiretroviral therapy
Tuberculosis - A Challenging Problem. initiation in patients with tuberculosis: find-
(2013). Online Information Video. Ac- ings from the SAPiT trial. Ann Intern Med.
cessed via URL: http://www.tbcoalition. (2012). 157:313-324.
eu/2013/03/25/extrapulmonary-tuberculo- 37. Department of Health Republic of South