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Post-tuberculosis bronchial asthma

Article  in  The Indian journal of tuberculosis · July 2001

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Original Article Ind.J Tub., 2001,48,139

POST-TUBERCULOSIS BRONCHIAL ASTHMA*

S. Rajasekaran1, S. Savithri2 and D. Jeyaganesh2

Summary:
Background: Asthma is a chronic inflammatory disorder of airways. The Th 2 lymphocytes, responsible for immediate
type hypersensitivity in asthma do not co-exist with Th 1 lymphocytes produced as a part of cell
mediated enhanced effects of immunological response (CMI) in active tuberculosis. Hence, co-occurrence
of asthma and active tuberculosis is uncommon.
Objectives: To assess the time of occurrence and severity of post- tuberculosis bronchial asthma
To evaluate the response to anti-asthma management and implications of long-term corticosteroid
administration in such cases
To follow up these patients for occurrence of airways obstruction and respiratory disability.

Methodology :Fifty-five adult wheezcrs, who were attending Government Raja Mirasudar Hospital, Thanjavur as
confirmed pulmonary tuberculosis patients for which they had complete courses of anti-tuberculosis
treatment and proven post-tuberculosis bronchial asthma were assessed for pulmonary functions, before
and after hronchodilntor therapy, on each visit.
Results: Bronchial asthma had emerged within 3 years of slopping anti-tuberculosis treatment in 42(76.3%)
patients. Two-thirds had no familial history of asthma. Patients with moderate and far-advanced residual
lung lesions had more persistent symptoms and low PEFR levels requiring prolonged corticosteroid
administration. None of the 55 patients studied had relapsed in the 2 year follow-up despite most of them
being on prolonged corticosteroid therapy.
Conclusion: Post-tuberculosis bronchial asthma patients, with moderate or far advanced residual lesion, had more
peisistent symptoms needing continued corticosteroids therapy.

Key words: Asthma & tuberculosis. Post-tuberculosis asthma.

INTRODUCTION of anti-tuberculosis treatment, 2) to analyse the

severity of asthma in relation to the radiological extent
Bronchial asthma is a major global health of healed residual tuberculous lung lesions, 3) to
problem affecting people of all ages. Similarly, evaluate the response to management of post-
tuberculosis is a global emergency needing tuberculosis asthmatics and 4) to observe long-term
aggressive control measures. However, both these effects of corticosteroid therapy.
health problems do not reach peak of activity
simultaneously due to different immunological MATERIAL AND METHODS
mechanisms requiring Th1 and Th2 lymphocytes for
mediating tuberculosis and asthma respectively. A Fifty-five post-tuberculosis adult whcc/ers
proportion of pulmonary tuberculosis patients later who were attending the Department of Thoracic
develop asthma, after the enhanced Thl Medicine, Government Raja Mirasudar Hospital,
lymophocytes have been reduced to the normal level Thanjavur (Tamilnadu) were studied.
with anti-tuberculosis treatment. Airways obstruction
is one of the known complications / sequelae of Inclusion criteria: 1) Patients should have confirmed
tuberculosis 1 , which on aggravation emerges as diagnosis of pulmonary tuberculosis, 2) they should
bronchial asthma. have successfully completed the stipulated course of
anti-tuberculosis treatment, and 3) they should have
OBJECTIVES confirmed post-tuberculosis bronchial asthma.

The aims of this study were 1) to assess the Exclusion criteria: 1) Patients having associated
time of occurrence of bronchial asthma after stoppage disorders like cor pulmonale, cardiovascular

*Papcr presented at the 55th National Conference on Tuberculosis and Chest Diseases held in Kolkata, 7-10 December, 2000
1. Professor of Thoracic Medicine. 2. Post graduate.
Department of Thoracic Medicine. Government Raja Mirasudar Hospital, Thanjavur
Correspondence : Dr. S. Rajasekaran. Deputy Superintendent, Government Hospital of Thoracic Medicine. Tambaratn Sanatorium. Chennai - 600 047
The Indian Journal of Tuberculosis
140 RAJASEKARAN E T A L

abnormalities, renal disorders, diabetes mellitus and Table 1 : Time of Occurrence :Post-Tuberculosis
other immunosupprcssivc problems, 2) Non- Asthma
compliant patients, 3) Patients with relapsed
pulmonary tuberculosis, and 4)Palicnts in moribund After treatment Number of patients %
condition. duration(years)

Investigations: The following investigations were ≤1 28 50.9

done for each patient :-
1. Sputum smear-microscopy for AFB (three
specimens),
2. X-ray chest - PA view,
3. Peak Expiratory Flow Rate (PEFR) - measured
at each visit, before and after bronchodilator
administration as percentages of predicted values
calculated on the basis of normal values of south
Indian population, and
4. Other routine investigations.
FINDINGS
A. The demographic variables in respect of the
studied patients were :
Total number of patients : 55
(43 Males + 12 Females)
Family History of Asthma/Allergy : 14
Smokers : non smokers : 20:35
B. Time of occurrence of asthma after stopping
chemotherapy:-Forty two patients (76.3%) had
developed bronchial asthma within three years of
stopping anti-tuberculosis treatment; 23 (41.8%)
noticed a ‘wheeze’ within a period of 6 months (Table
1). Of the 14 patients, who had familial history of
asthma, 9 (64.3%) had first-time asthma
manifestation within a year of stopping
chemotherapy.
1-3 14 25.4
4-6 4 7.3
>6 9 16.4
C. Severity of asthma in relation to radiological
extent of residual healed tuberculous lesions:Of the
14 patients who had minimal residual lung lesion,
11(78.6%) had intermittent asthma (Table 2); 27
(81.8%) of 33 patients with moderate residual lesions
and all the 8 patients with far advanced lesions had
varied degree of persistent asthmatic manifestations.
The Peak Expiratory Flow Rate levels
(% of predicted value) among the post-tuberculosis
asthmatics (Table 3) varied with the radiological
extent of residual lung lesions: 26 patients (78.8%)
with moderate residual lesions and all the 8 patients
with far advanced lesions had PEFR £ 60% of the
predicted value. Prolonged corticosteroid
administration was found necessary in most of these
patients.
D. Follow-up assessment:All the patients were
followed up for 2 years. None of the 55 patients
relapsed till the end of the follow up. The patients
who had moderate to far advanced residual healed
lung lesions, required prolonged administration of
corticosteroids.

Table 2 : Severity of asthma in relation to extent of residual/healed pulmonary tuberculosis lesions

Severity* of asthma Extent of healed lung lesions Patients

Minimal Moderate Far Advanced No. %

Intermittent 11 6 - 17 30.9
Mild persistent 2 7 1 10 18.2
Moderate persistent 1 15 2 18 32.7
Severe persistent - 5 5 10 18.2
Total 14 33 8 55 100

* Based on symptoms : cumulative analysis of multiple visits

The Indian Journal of’ Tuberculosis
 POST-TUBFRCULOSIS BRONCHIAL ASTHMA
Table 3 : PEFR levels in relation to extent of residual/healed pulmonary tuberculosis lesions
PEFR* Extent of healed lung lesions
(% of predicted)
Minimal Moderate
≤40 - 4
41-60 2 22
61-80 10 7 -
>80 2 -
Total 14 33
* Representative values of multiple assessments
DISCUSSION
Post-tuberculosis bronchial asthma is a
separate clinical entity. It requires insight,
understanding and evaluation of its,evolution, clinical
course and management. The present study,
accordingly, assessed the lime of its occurrence,
severity and frequency of asthma, the response to
management, steroid dependency and complications
relating to relapsed tuberculosis.
Pulmonary impairment associated with
obstructive airways disease is recognised as a
common complication of advanced tuberculosis.
Airways obstruction has been noticed more frequently
among older men with far advanced pulmonary
tuberculous lesions who smoke1; most tuberculous
patients with moderate to far advanced post-treatment
residual lung lesions exhibit symptoms of impaired
pulmonary functions due to persistent airways
obstruction, but only a small proportion develop
reversible airways obstruction to qualify for post-
tuberculosis bronchial asthma categorization.
Of the 55 patients with post-tuberculosis
bronchial asthma studied, only 14 patients (25.5%)
had familial history of allergy and asthma; smoking
was the associated factor in 20 males (36.4%). The
time of occurrence of post-tuberculosis asthma was
variable; nearly 50% of the study group developed
reversible airways obstruction within one year of
stopping chemotherapy, while the rest developed
asthma from one to ten years after stoppage of
chemotherapy.
The mechanism of evolution of post-
tuberculosis bronchial asthma is related to the 2. Whether familial susceptibility to asthma &
The Indian Journal of Tuberculosis
141
Patients
Far Advanced No. %
4 8 14.6
4 28 50.9
17 30.9
- 2 3.6
8 55 100.0
immunopathogenesis of tuberculosis and bronchial
asthma. The Thl and Th 2 sub-groups of T
lymphocytes regulate development of tuberculosis
and bronchial asthma and their levels are not enhanced
simultaneously. This explains why the clinical
manifestations of both the disorders do not occur at
the same time.
The Th 1 lymphocytes preferentially produce
and secrete IL-2 which stimulates T lymphocyte
proliferation and Interfcron-gamma formation. IFN-
gamma in turn inhibits B cell activation and the
resultant IgE synthesis (Fig.l). Thus, IL-2 triggered
pathway is responsible for the type IV
hypersensitivity reaction2-4. The Th 2 lymphocytes,
on the other hand, produce and secrete IL-3, IL-4,
IL-5, IL-9 and IL-13; the specific actions of these
interleukins on B lymphocytes, mast cells and
eosinophils produce the characteristic inflammatory
response of asthma.2-4 Recent studies3,5 support this
hypothesis by demonstrating an increased proportion
of Th 2 lymphocytes in the peripheral blood and
airways of patients with asthma and allergic
disorders.
Two questions still remain unanswered -
1. Why do all the pulmonary tuberculosis patients
not develop bronchial asthma after successful
completion of anti-tuberculosis treatment ? And,
whether the CMI / DTH response is retained,
with the possible presence of a few inactive M.
tuberculosis even after treatment?
 142 RAM SF.KARAN ET AL

Fig 1: Schematic representation of the roles played by Th land Th 2 lymphocytes in tuberculosis and
bronchial asthma

allergy are essential factors for post-tuberculosis REFERENCES

bronchial asthma ?
This study had only 25% of patients with
familial background of atopy. More studies on
genetics, immunopathogencsis & molecular biology
arc required to better understand this clinical
condition because post-tuberculosis bronchial asthma
is a distinct clinical entity, especially in patients with
moderate to far advanced residual lung lesions,
requiring prolonged administration of corti-
costcroids. Relapsed tuberculosis is rare in this clinical
condition, even after prolonged steroid treatment.
1. Snider GL, Doclor L, Demas TA, Shaw AR. Obstructive
airways disease in paiients with treated pulmonary
tuberculosis. Am Rev Respir Dis; 1971,103,625
2. De prete G. Human Th 1 and Th 2 lymphocytes : their role
in the pathophysiology of atopy. Allergy; 1992,47,450
3. Romagnani S. Lymphokine production by human T cells
in disease slates. Ann Rev Immunol; 1994,12,227
4. Romagnani S. Role of Th 2 lymphocytes in the genesis of
allergic disorders and mechanisms involved in their
development, in Holgate ST et al (eds). Asthma: Physiology,
Immunopathology and Treatment. Academic Press,
London;1993,Ch 13
5. Holgate S. Mediator and cytokine mechanisms in asthma.
Thorax; 1993,48,103

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