ORIGINAL ARTICLE

Tanaffos (2008) 7(1), 52-57

©2008 NRITLD, National Research Institute of Tuberculosis and Lung Disease, Iran

Pulmonary Tuberculosis in the Elderly

Mohammad Towhidi 1, Azita Azarian 2, Amir Asnaashari 1

1 Department of Internal Medicine, Pulmonary Division, 2 Department of Radiology, Ghaem Hospital, Mashhad University of Medical
Sciences, MASHHAD - IRAN.

D
ABSTRACT
Background: Despite the increased rate of tuberculosis (TB) in the elderly, few publications have presented the clinical

SI
characteristics of TB in this specific age group in our country. This study aimed to compare the clinical features, predisposing
factors and imaging findings of pulmonary TB in the elderly and in young adults, and to determine if any difference exists
between the two groups.
Materials and Methods: We retrospectively reviewed the records of all patients with the diagnosis of pulmonary TB at
of
Ghaem Hospital and outpatient clinics during a 6-year period. Ninety-five patients were studied and divided into two groups,
33 patients were in the young group (mean age, 29.3 yrs.) and 40 patients in the elderly group (mean age, 69.6 yrs.).
Patients aged 46-64 were excluded from the study.
Results: Predisposing factors were more prevalent in the elderly who had a significantly higher frequency of chronic
ive

obstructive pulmonary disease, ischemic heart disease, congestive heart failure, malignancy and diabetes mellitus.
Pregnancy and postpartum status were the predisposing conditions in young females. The classic symptoms and signs of TB
were noted in a higher proportion of the younger group. Fever (78% vs. 57.5%), and weight loss(94% vs. 80%) were
significantly higher (p<0.05),while night sweats(24% vs. 22.5%),cough (100% vs. 92.5%) and hemoptysis(30% vs. 15%),
ch

were seen more in the younger group but with no significant differences .Lower lung infiltrates were higher in the elderly;
whereas, cavitation was seen significantly more in the young age group(63% vs. 25%, p<0.05).
Conclusion: To prevent delay in diagnosis and treatment, TB should be considered among the differential diagnosis of any
Ar

type of pulmonary infiltrates seen in the elderly, even when the clinical presentation is atypical. (Tanaffos 2008; 7(1): 52-57)
Key words: Pulmonary Tuberculosis, Young, Elderly

INTRODUCTION
Today, tuberculosis (TB) remains one Mycobacterium tuberculosis and 7-8 million people
of the world's most lethal diseases. An estimated develop TB each year (1). Despite the steady decline
one-third of the world's population is infected with in the rate of TB cases resulting from the overall
Correspondence to: Towhidi M
implementation of effective TB control programs,
Address: Department of Internal Medicine, Ghaem Hospital, Mashhad, Iran. directly observed treatment short course (DOTs), and
Email address: dr_mtowhidi@yahoo.com efforts to control the human immunodeficiency virus
Received: 6 May 2007
/ acquired immunodeficiency syndrome (HIV/AIDS)
Accepted: 26 Nov 2007

www.SID.ir
 Towhidi M, et al. 53

epidemics, preventive and control strategies among and patients aged 65 or older. Patients aged 46 -64
other high-risk populations (such as the elderly) were excluded from the study. Thirty-three patients
remains a clinical and epidemiological challenge. were included in the younger group and 40 patients
Although infection with human immunodeficiency in the elderly group. Whenever sputum smear for
virus (HIV) is the greatest risk factor for acid fast bacilli (AFB) was negative or the patient
development of TB, the elderly are particularly at had no sputum, he or she underwent fiberoptic
risk for development of this disease (2). The geriatric bronchoscopy with bronchial washing and bronchial
population represents the largest reservoir of TB biopsy if an endobronchial lesion was seen.
infection particularly in developed countries (1). The collected data included demographic
Twenty-six percent of TB cases diagnosed were 65 characteristics, history of previous TB, symptoms,
years and older, but 60.3% of TB cases diagnosed at presence of conditions predisposing to pulmonary

D
death were in this age group (3). TB, bacteriologic status, and results of
It has been suggested that TB in the elderly may histopathologic examination.

SI
differ from TB presenting in younger patients, and Statistical analysis: Statistical analysis was done
that it should be classified as a separate entity (4,5). using SPSS software; differences between the means
These differences might account for delay in were compared using one way analysis of variance.
diagnosis, which in turn leads to morbidity and To determine the significance of correlations
of
mortality in this age group (6,7). Few publications between the measurements, the Chi-square test was
have presented clinical and radiological used.
characteristics of pulmonary TB in the elderly in our
country (8,9). RESULTS
ive

We aimed to study all patients with pulmonary TB The characteristics of the patients are summarized
diagnosed at Ghaem Hospital and outpatient clinics in Table 1.
and to compare clinical characteristics,
roentgenographic findings and predisposing factors Table 1. Pulmonary TB in the elderly: Patients’ characteristics.
ch

between the young and elderly patients.

Characteristics Young(n =33) Elderly(n =40)
Age(year) (mean ± SD) 29.3 ± 10.l 69.6± 6.1
MATERIALS AND METHODS Male/Female 12/21 21/19
We reviewed the records of all patients with the Afghan immigrant 1 1
Ar

diagnosis of pulmonary TB documented by positive Duration of symptoms (days prior to

3-360 21-720
diagnosis) Range
smear and/or culture of sputum for Mycobacterium
Mean 82 103
tuberculosis, positive smear and/or culture of
bronchial washing and positive biopsy specimen for During the study period, there were 95 cases of
granuloma with or without caseation necrosis who TB, 40 cases included in the elderly group with the
were admitted to Ghaem Hospital or visited at the age range of 65-90 years (mean age, 69.6 yrs.) and
outpatient clinics of Mashhad University of Medical 33 cases included in the young group with the age
Sciences during a 6-year period. range of 15-45 years (mean age, 29.3 years). There
A total of 95 patients were included in the study. were only 2 Afghan immigrants among our patients,
For the analysis of clinical features, the patients were one in each group. Underlying diseases were more
divided into two groups: Patients aged 45 or younger prevalent in the elderly patients. The elderly had

Tanaffos 2008; 7(1):52-57

www.SID.ir
54 Pulmonary Tuberculosis in the Elderly

higher frequency of chronic obstructive pulmonary Upper lobe infiltrations were noted significantly
disease (COPD), ischemic heart disease (IHD), more in the younger group (54.5% vs. 15%)
congestive heart failure (CHF), malignancy (2 cases (p<0.05), whereas lower lung field infiltrations were
of bronchogenic carcinoma and 1 gastric carcinoma) seen more in the elderly group (35% vs. 24%), but
, and diabetes mellitus (Table 2); whereas, pregnancy differences were not statistically significant.
and postpartum state were the predisposing Cavitation was present significantly more in the
conditions in young females. Classic symptoms younger group compared to the elderly (63% vs.
described for TB such as fever (78%vs. 57.5%) and 25%, p<0.05) (Table 4).
weight loss (94% vs. 80%), were noted in a
significantly higher proportion among the younger Table 4. Pulmonary TB in the elderly : Radiological findings.

group (p<0.05) than in the elderly. Although night

D
Young (n = 33) Elderly (n = 40)
sweats (24% vs. 22.5%), cough (100% vs. 92.5%) Radiological findings P value *
Number (%) Number (%)
and hemoptysis (30% vs. 15%) were seen more in the Upper lobe infiltration 18 (54.5) 6 (15) 0.001

SI
younger age group, the differences were not Lower lung field
8 (24) 14 (35) 0.1
statistically significant (Table 3). infiltration
Cavitation 21 (63) 10 (25) 0.001
Miliary - 1 (2.5) -
Table 2. Pulmonary TB in the elderly: Underlying diseases.
* p<0.05 was considered as significant.
of
Young (n = 33) Elderly (n = 40)
Underlying disease Sputum was the most common source for the
Number (%) Number (%)
COPD (chronic bronchitis) - 3 (7.5) diagnosis of pulmonary TB in both groups. Nine
IHD, CHF - 2 (5) patients in the elderly and one patient in the younger
ive

Diabetes mellitus 1 (3) 3 (7.5)

group underwent fiberoptic bronchoscopy for the
Malignancy - 3 (7.5)
Pregnancy and postpartum 5 (15) -
diagnosis of pulmonary TB.
CVA - 1 (2.5)
Pulmonary hydatid cyst 1 (3) - DISCUSSION
ch

History of previous TB 1 (3) 2 (5) TB is still a major cause of morbidity and

Total 8 (24) 14 (35)
mortality worldwide. Recent studies have suggested
COPD : Chronic obstructive pulmonary disease.
IHD : Ischemic heart disease.
that even in the developed world, its incidence in the
elderly is increasing (10). Prior to onset of HIV-
Ar

CHF : Congestive heart failure.

CVA : Cerebrovascular accident. associated TB, the elderly, newly arrived immigrants
and minority population, were the groups in the
Table 3. Pulmonary TB in the elderly: Clinical features.
North America whose rate of disease continued to
Young ( n = 33) Elderly(n = 40) rise(7,11). The elderly have documented very high
Clinical features P value *
Number (%) Number (%) rates of disease particularly in nursing homes
Fever 26 (78) 23 (57.5) 0.046 (12).From the public health point of view,
Weight loss 31 (94) 32 (80) 0.049 unrecognized pulmonary TB specially among the
Night sweats 8 (24) 9 (22.5) 0.508
elderly is of greater importance, because it often may
cough 33 (100) 37 (92.5) 0.297
Hemoptysis 10 (30) 6 (15) 0.156 lead to premature death as well as unrecognized
Abnormal mentation - 2 (5) 0.277 transmission of infection in the community(3).
* p<0.05 was considered as significant. Twenty-six percent of cases diagnosed alive were

Tanaffos 2008; 7(1):52-57

www.SID.ir
 Towhidi M, et al. 55

among those of 65 years and older, but 60.3% of TB related to the fact that it was a registry -based series
cases diagnosed at death were in this age group. and therefore, a number of cases would have been
These data indicate that TB often remains diagnosed in the process of contact evaluation.
unrecognized and to prevent continuing deaths due to In contrast to others, in a study from Strasbourg
this curable disease, a high index of suspicion of TB (19) comparison of the clinical and radiological
remains important particularly among the elderly and features of TB showed no significant difference
those with extrapulmonary sites of disease (3). Delay between the young and elderly patients. In another
in diagnosis of TB causing avoidable morbidity and study from Tehran (8), the authors reached the same
mortality has often been assumed (particularly in the conclusion.
elderly) to be associated with atypical clinical and Our study confirmed the findings of Alvarez (14),
radiological features (13). One feature of TB among Rizvi (16), Zamarron (17), Chan(18), Khan(20) and

D
the elderly was the frequent association of other Leung(29) that the elderly patients had higher
comorbid conditions such as malignancy, diabetes number of underlying disease than young patients

SI
mellitus, ischemic heart disease and chronic and had less fever, hemoptysis and more non-specific
bronchitis (14,15). In our patients , the elderly group complaints. Chest radiograph in the elderly patients
had higher number of underlying diseases than the with TB had atypical appearance and these patients
younger group( 35% vs. 24%). Concurrent diagnosis were less likely to have upper lobe infiltration and
of
of TB and malignancy was seen in 3 out of 40 elderly more commonly had extensive infiltration of both
patients (7.5%). Two patients had bronchogenic lung fields and lower lobes infiltration.
carcinoma and one had gastric carcinoma who Our data confirmed the previous reports that a
underwent gastrectomy. relatively high proportion of patients with pulmonary
ive

In Alvarez series, 3 out of 29 (10.3%) young TB in all age groups had atypical radiological
patients and 11 out of 35 (31%) elderly patients had findings (20,21). In our series, the only exception
an underlying malignancy (14). In our patients, regarding radiological features was that the
pregnancy and postpartum state were seen in 5 out of frequency of cavitation was significantly lower in the
ch

33 (15%) of the young group as the underlying risk elderly patients (63% vs. 25%, p<0.05). This was
factors. Our data suggested that younger patients similar to the radiological findings of Perez-Guzman
were more likely to have fever, night sweats, weight (22, 23), Yamaguchi (24) and Lee (27).
loss and hemoptysis than the elderly. Similar to our In another study done by Liaw et al. (28),
Ar

patients, these differences in symptoms have been radiographic presentation as mass lesions was more
reported previously in hospital-based retrospective frequently encountered in elderly patients (10.5% vs.
series (14), which consisted only of male subjects 2.1%, p< 0.05).
selected among the hospitalized patients. It has been stated that Mantoux skin testing with 5
In a prospective comparative study, TU PPD was a relatively inefficient adjunct in the
Korzeniewska-Kosela (11) concluded that although diagnosis of active TB. But in a population-based
younger patients were more likely to have fever, study by Korzeniewska-Kosela (11) skin test
night sweats and hemoptysis, there was no significant responses to 5 TU PPD were positive in 86.2% of
difference in most symptoms between the two young adults and 67.6% of elderly patients.
groups. In their study, small but significant minority In our patients, diagnosis of pulmonary TB was
of patients were asymptomatic, probably in part confirmed by fiberoptic bronchoscopy (FOB) in 9

Tanaffos 2008; 7(1):52-57

www.SID.ir
56 Pulmonary Tuberculosis in the Elderly

elderly patients (22.5%) who had either no sputum or 7. Rieder HL, Cauthen GM, Comstock GW, Snider DE Jr.
negative sputum smear. The usefulness of fiberoptic Epidemiology of tuberculosis in the United States. Epidemiol
bronchoscopy in diagnosis of smear negative Rev 1989; 11: 79- 98.
pulmonary TB has been reported in our previous 8. Yekani F, Samar G, Amoli K. Tuberculosis presentation in
study (25). young and elderly patients. Iranian journal of Infectious
We have previously suggested that elderly diseases & Tropical Medicine 1999; 11(4): 57-60.
patients suspected to have TB with lower lung field 9. Aminzadeh Z, Gachkar L, Ghorbani G. Relationship of age
infiltration are those who will more likely benefit to clinical and radiographic manifestations of tuberculosis.
from FOB, bronchial washing and biopsy to reach an Pejouhandeh 1999; 15(4): 273-7.
early diagnosis. This is due to the fact that patients 10. Packham S. Tuberculosis in the elderly. Gerontology 2001;
with lower lung field TB are more likely to have 47 (4): 175- 9.

D
endobronchial TB (25,26). 11. Korzeniewska-Kosela M, Krysl J, Müller N, Black W, Allen
In conclusion, we showed that TB in the elderly E, FitzGerald JM. Tuberculosis in young adults and the

SI
was associated less often with classic symptoms of elderly. A prospective comparison study. Chest 1994; 106
fever, weight loss, night sweats and hemoptysis and (1): 28- 32.
more often with non-specific symptoms. Underlying 12. Stead WW, Lofgren JP, Warren E, Thomas C. Tuberculosis
conditions are more often present in the elderly than as an endemic and nosocomial infection among the elderly in
of
in young adults. nursing homes. N Engl J Med 1985; 312 (23): 1483- 7.
Roentgenographic appearance of TB in the elderly 13. Katz I, Rosenthal T, Michaeli D. Undiagnosed tuberculosis
is associated more often with lower lung infiltration, in hospitalized patients. Chest 1985; 87 (6): 770- 4.
but cavitation is significantly less often seen in the 14. Alvarez S, Shell C, Berk SL. Pulmonary tuberculosis in
ive

elderly patients. A high index of suspicion must be elderly men. Am J Med 1987; 82 (3 Spec No): 602- 6.
maintained to identify the disease in the elderly in 15. Kaplan MH, Armstrong D, Rosen P. Tuberculosis
order to prevent transmission of infection to others. complicating neoplastic disease. A review of 201 cases.
Cancer 1974; 33 (3): 850- 8.
ch

REFERENCES 16. Rizvi N, Shah RH, Inayat N, Hussain N. Differences in

1. Rajagopalan S, Yoshikawa TT. Tuberculosis in the elderly. Z clinical presentation of pulmonary tuberculosis in association
Gerontol Geriatr 2000; 33 (5): 374- 80. with age. J Pak Med Assoc 2003; 53 (8): 321- 4.
2. Stead WW, Lofgren JP. Does the risk of tuberculosis 17. Zamarrón C, Salgueiro M, Alvarez JM, Otero Y, Rodríguez
Ar

increase in old age? J Infect Dis 1983; 147 (5): 951- 5. Súarez JR. The clinical characteristics of pulmonary
3. Rieder HL, Kelly GD, Bloch AB, Cauthen GM, Snider DE tuberculosis in the elderly. An Med Interna 1997; 14 (4):
Jr. Tuberculosis diagnosed at death in the United States. 167- 9.
Chest 1991; 100 (3): 678- 81. 18. Chan CH, Woo J, Or KK, Chan RC, Cheung W. The effect
4. Morris CD. The radiography, haematology and biochemistry of age on the presentation of patients with tuberculosis.
of pulmonary tuberculosis in the aged. Q J Med 1989; 71 Tuber Lung Dis 1995; 76 (4): 290- 4.
(266): 529- 36. 19. Kaltenbach G, Grunenberger F, Schlienger JL, Berthel M,
5. Morris CDW. Pulmonary tuberculosis in the elderly: a Imler M, Kuntzmann F. Influence of age on presentation and
different disease? (Editorial), Thorax 1990; 45: 912-13. prognosis of tuberculosis in internal medicine. Presse Med
6. Stead WW, Dutt AK. Tuberculosis in the elderly. Semin 2001; 30 (29): 1446- 9.
Respir Infect 1989; 4 (3): 189- 97.

Tanaffos 2008; 7(1):52-57

www.SID.ir
 Towhidi M, et al. 57

20. Khan MA, Kovnat DM, Bachus B, Whitcomb ME, Brody JS, 25. Towhidi M. Rapid diagnosis of suspected pulmonary
Snider GL. Clinical and roentgenographic spectrum of tuberculosis by flexible fiberoptic bronchoscopy and
pulmonary tuberculosis in the adult. Am J Med 1977; 62 (1): transbronchial biopsy. Iran J Med Sci 1991; 16: 74- 7.
31- 8. 26. Keshmiri M, Towhidi M. Roentgenographic and

21. Hadlock FP, Park SK, Awe RJ, Rivera M. Unusual bronchoscopic findings in sputum smear-negative pulmonary

radiographic findings in adult pulmonary tuberculosis. AJR tuberculosis. M J IRI 1994; 7: 239- 43.

Am J Roentgenol 1980; 134 (5): 1015- 8. 27. Lee JH, Han DH, Song JW, Chung HS. Diagnostic and

22. Pérez-Guzmán C, Vargas MH, Torres-Cruz A, Villarreal- therapeutic problems of pulmonary tuberculosis in elderly

Velarde H. Does aging modify pulmonary tuberculosis?: A patients. J Korean Med Sci 2005; 20 (5): 784- 9.
28. Liaw YS, Yang PC, Yu CJ, Wu ZG, Chang DB, Lee LN, et
meta-analytical review. Chest 1999; 116 (4): 961- 7.
al. Clinical spectrum of tuberculosis in older patients. J Am

D
23. Perez-Guzman C, Torres-Cruz A, Villarreal-Velarde H,
Geriatr Soc 1995; 43 (3): 256- 60.
Vargas MH. Progressive age-related changes in pulmonary
29. Leung CC, Yew WW, Chan CK, Chau CH, Tam CM, Lam
tuberculosis images and the effect of diabetes. Am J Respir

SI
CW, et al. Tuberculosis in older people: a retrospective and
Crit Care Med 2000; 162 (5): 1738- 40.
comparative study from Hong Kong. J Am Geriatr Soc
24. Yamaguchi Y, Kawabe Y, Nagayama N, Tamura A, Nagai
2002; 50 (7): 1219- 26.
H, Akagawa S, et al. A study on the clinical features of
pulmonary tuberculosis in elderly patients. Kekkaku 2001;
of
76 (6): 447- 54.
ive
ch
Ar

Tanaffos 2008; 7(1):52-57

www.SID.ir