Case Report

Ind. J Tub., 2002,49, 157

ACUTE RADIOLOGICAL CHANGE IN ADULT PULMONARY TUBERCULOSIS*

G. Behera1**, K.L. Dei2*** , R.N. Mania1**and H.K. Naik3

Summary :A case is presented in which tuberculous cavitation appeared radiologically within a fortnight. _______________

INTRODUCTION
Tuberculosis is a chronic disease with an insidious onset. Is it always so and, alternatively, can it manifest as an acute disease? It is a standard teaching that if the onset is acute, then the cause is probably non-tuberculous. Inspite of a number of studies on tuberculosis in adults, there is no certain knowledge on the actual appearance of demonstrable lesion in incipient disease. The minimum time it takes for an incipient lesion to develop into advanced smear positive tuberculosis is not known. Radiologically, incipient tuberculosis manifests as a small infiltrate in upper lobe either in the apical or the sub-apical areas. At this point, the symptoms are mild or totally absent . From this stage onwards, tuberculosis develops in phases. After months and years, the lesion occasionally gets arrested but usually it deteriorates. Each worsening, as a rule, is acute in character while regressive changes are slow and chronic. Thus, the deterioration phase is perhaps accompanied by pronounced symptoms whereas in regressive phase, symptoms are relatively mild1. Amberson2 found that apical small lesions were mostly old and chronic. If recent, the prognosis is good because less than 10% develop tuberculosis within 5-10 years 2 & 90% do not require any treatment at all3. A majority believe that early infraclavicular infiltrate is the true beginning of tuberculosis1. It is stressed that an exudative lesion
1 Assistant Professor 2 Associate Professor 3 Post-graduate student ** Department of TB and Chest Diseases *** Department of Pathology SCB Medical College, Cuttack

tends to cavitate while others believe that there is already cavitation1. Lastly, a large proportion of cases start with a massive pneumonic involvement without ever passing through a minimal phase4. A lesion of a few months duration may be minimal or far advanced but without having any relation with it being early, incipient or chronic old lesion (which indicate time dimension) or it being minimal, moderately advanced or far advanced lesion (which indicate the volume of lung involved). For reasons not yet fully known, tubercle bacilli grow at a very low speed in certain lesions and, thus, are present in small numbers while in other lesions they may multiply rapidly. Therefore, it is wrong to regard all patients with cavity, smear positive tuberculosis as old and chronic cases1. From longitudinal mass x-ray surveys, it has become obvious that : a) a large proportion of new lesions, starting in a normal lung, develop within months, b) even those lesions that are advanced and are discharging large number of bacilli demonstrable by microscopy, probably develop fast, c) a case of advanced, smear positive tuberculosis, when seen for the first time, is not necessarily old or chronic; it may well be a recent minimal lesion, positive by culture only; and d) both types of disease advanced, smear positive tuberculosis and minimal, culture only positive tuberculosis develop within the same time frame. Thus, it is likely that the smear positive cases develop

*Paper presented at the 56th National Conference on Tuberculosis and Chest Diseases held in Chennai, 9 12, October 2001

Indian Journal of Tuberculosis

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so fast that they do not pass through a perceptible minimal phase1. We have observed 7 cases which were thought to be non-tuberculous due to acute onset of symptoms and radiological changes. In all the 7 cases, the symptoms were so acute that diagnosis of tuberculosis was not suspected and they were treated as lung abscess. Four of them returned after four to six weeks and were diagnosed to be pulmonary tuberculosis by sputum AFB only. Given below is a case report of one such case.

Sputum for AFB on 3 consecutive samples was negative, on 4th sample it was Sc - 3+. Repeat chest X-Ray was done on 6/5/2000, which showed a cavity and new infiltration in right lung (Figure 2). Sputum for culture showed no growth again.The patient responded well to anti-tuberculosis treatment.

CASE REPORT
HF, a patient aged about 24 years, had a history of fever for about 6 weeks, cough & anorexia for 4 weeks. The fever was of acute onset not associated with rigor and chill. She had taken some symptomatic treatment but was not relieved. Then she took Amoxycillin 500 mg three times daily for about a week or so, but the symptoms continued for which she was referred to us. On examination of chest, there were normal bilateral vesicular breath sounds. Crepitations were heard over right upper intra-scapular region. The previous chest X-ray dated 24/4/2000 showed infiltration over left lower zone only (Figure 1).

Figure 2: Repeat chest X-ray showing a cavity and new infiltration in right lung CONCLUSIONS
1. 2. 3. A sudden symptomatic onset is not less frequent in pulmonary tuberculosis. The extent of the lesion does not bear a direct relation to the duration of the disease. Cavitation is not a late occurrence. Its frequency is nearly the same in all stages of the disease. All the patients with chest symptoms should be X-rayed and sputum should be examined for AFB irrespective of suggestions of other diseases.

4.

REFERENCES Figure 1: Chest X-ray showing an infiltration over lower left zone only Investigations showed TLC 9,600/cu.ml, DLC N/39, E/13, L/47, M/1, Hb 8.6 g%, Serum Bilirubin- 0.3mg% (direct), 0.8mg% (total) and ELISA negative for HIV.
Indian Journal of Tuberculosis
1. 2. 3. 4. K. Toman, Tuberculosis Case-finding & Chemotherapy, 2nd Edn. (1994). Amberson, J.B. Jr. Journal of American Medical Association, 1937, 109. 1949. Pinner, M. Pulmonary tuberculosis in the adult. Springfield, Il, Thomas, 1946. Douglas, BH. et, al, Am. Rev Tuberc , 31:162 (1935).

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