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http://dx.doi.org/10.1016/j.jctube.2016.03.001
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/ Journal of Clinical Tuberculosis and Other Mycobacterial Diseases 3 (2016) 10–12 11
that investigated obstructive Lung disease in the community, the Other long term complications of PTB include airway stenosis
overall prevalence of airflow obstruction defined as FEV1/FVC ratio (tracheal or bronchial stenosis) and fistulae formations (trachea-
post-bronchodilator of less than 0.7 was 30.7% among those with esophageal fistula) all of which threaten life. These complications
a history of tuberculosis, compared with 13.9% among those with- have mostly been reported as case reports or small case series and
out this history [23]. A recent systematic review examining the re- therefore their incidence in patients who suffer PTB is currently
lationship between pulmonary TB and COPD in community based unknown.
studies found a consistent association across the two community
based studies identified with odds ratios ranging from 1.78 to 6.31,
between a reported history of TB and Spirometry confirmed COPD What needs to be done?
among people aged 40 years and above. The risk of COPD was cor-
related to the TB incidence of the country [24]. This subject has Robust epidemiological studies to determine rates of occurrence
recently received a lot of attention in the realm of the Burden of and risk factors for these complications are lacking which has con-
Lung Disease (BOLD) initiative [25,26]. Thus the experience of an tributed to the lack of attention given to these problems by na-
episode or more of lung TB poses a significant risk of obstructive, tional TB control programs. Of the many possible complications of
restrictive and combined ventilatory lung defects which may be PTB, COPD, Bronchiectasis and CPA stand out as the most common
progressive leading to progressive deterioration of quality of life problems that occur in significant numbers to require public health
and early mortality. attention at the global and country level.
Bronchiectasis is defined as the permanent dilatation and dis- The WHO’s ambitious End TB Strategy approved by all countries
tortion of the airways. It is clinically characterized by persistent [30] targets to reduce TB deaths by 90% in 2030 with intermedi-
cough with the production of sputum which in untreated patients ate milestones of reduction by 35% in 2020 and 75% in 2025. We
is often copious, purulent and associated with recurrent episodes argue that TB mortality must take into account deaths that occur
of hemoptysis. Bronchiectasis is a risk factor for community ac- following successful bacteriological treatment of PTB which means
quired pneumonia. Robust studies on the incidence of post TB that deaths due to the long term complications of PTB will need
bronchiectasis are unavailable, however in a review of this sub- to be factored into the quantification of deaths from TB. We there-
ject Toni Jordan et al indicated that the incidence of bronchiectasis fore propose that the public health implications of the long term
post PTB was in the range of 19–65% and in etiological studies of complications of PTB with a special emphasis on COPD, bronchiec-
bronchiectasis, TB is often the most common identified cause es- tasis and CPA, should be explored and appropriate public health
pecially in TB endemic settings [27]. The systematic review con- measures to deal with them elaborated and implemented. Here
ducted by Byrne Al et al found a significant association between we propose a list of actions that the global TB community in-
lung TB and bronchiectasis [24]. cluding national TB programmes need to undertake to elaborate
Aspergillus lung disease may present in three ways: invasive and evolve appropriate public health programs to confront these
Aspergillosis, a serious life threatening lung disease that presents problems.
as severe pneumonia; Allergic Bronchopulmonary Aspergillosis Firstly, we propose that the spectrum and magnitude of post
(ABPA) presenting as the syndrome of severe asthma with fungal TB chronic lung disease with a special focus on COPD, Bronchiec-
sensitization often with central Bronchiectasis and CPA which in tasis and CPA should be clearly established through the conduct of
post TB patients commonly presents as an Aspergilloma/mycetoma. robust epidemiological studies. Large multi country cohort studies
In post TB CPA, the fungus, most commonly Aspergillus fumigatus, may be used for this purpose. This could in the long run help to
colonizes cavities in the lung left behind by the TB. Precise esti- establish the cumulative incidence and the full spectrum of chronic
mates of the proportion of PTB patients who eventually develop respiratory disease post PTB and to characterize patients likely to
CPA are not available and neither have the risk factors for this suffer these clinical problems. Such understanding of the magni-
disease been fully identified. Based on studies conducted in the tude and spectrum of chronic respiratory disease post PTB can be
United Kingdom in the 1960’s where rates of radiologically identi- used to advocate for resources to manage PTB beyond cure of TB
fied Aspergilloma of up to 22% were found in patients with resid- as currently defined.
ual cavities following treatment for TB, Denning et al estimated Secondly, we suggest that the minimum set of clinical evalu-
that the incidence of CPA in patients previously treated for PTB ations and interventions that need to be carried out at the end
globally was 372,0 0 0 in 2007. The cumulative five year prevalence of treatment for PTB be defined. As discussed above the current
was estimated to be 1, 174 0 0 0, 852 0 0 0 and 1 372 0 0 0 cases at practice of using bacteriological clearance of Mycobacterium tuber-
15%, 25% and 10% annual attrition rates, respectively implying that culosis or completion of treatment as a measure of treatment suc-
CPA post PTB is a major global public health threat [28]. However, cess is likely to be missing a significant proportion of patients who
it is evident that the inputs into this modeling need to be updated need to continue to remain in care as a result of the episode of
with more recent clinical observations. PTB. This evaluation should include assessment of structural and
Characteristically CPA, presenting as a simple Aspergilloma will functional integrity of the lungs and associated symptoms and
manifest with the symptoms of prolonged malaise, cough and re- how these changes are impacting the quality of life of affected
current hemoptysis which can be massive and life threatening. The individuals. It is also important to assess patients for risk of and
diagnosis of CPA is dependent on clinical suspicion, availability and presence of fungal colonization or infection at the end of their
access to chest imaging with plain chest x-rays and CT scans and treatment in order to identify those who need additional care for
availability of serological testing for Aspergillus precipitins (IgG an- CPA.
tibodies). In many parts of the world where TB is endemic these Lastly, we propose that implementation science should be used
diagnostic necessities are not routinely available. Similarly, itra- to develop and assess the efficacy, effectiveness and costs of pub-
conazole, which has in recent studies been found to be efficacious lic health approaches for the delivery of care packages for post
in attenuating the clinical disease associated with CPA [29], may TB chronic respiratory disease. These care programs may be mod-
also not be available in low resource, high TB burden settings. The eled along those currently elaborated for other chronic respiratory
definitive treatment of CPA presenting as a simple Aspergilloma and non- respiratory diseases. Lessons learnt from the provision of
is surgical excision. The availability of cardiothoracic surgical ser- chronic care using the Practical Approach to Lung Health (PAL [31]
vices may also be severely limited in low resourced and high TB may be used to inform the design of care programs for chronic
endemic settings. respiratory disease resulting from PTB.
12 / Journal of Clinical Tuberculosis and Other Mycobacterial Diseases 3 (2016) 10–12
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