|Year : 2013 | Volume
| Issue : 3 | Page : 138-140
A rural medical college perspective for treating pulmonary and extrapulmonary tuberculosis in a hepatitis surface antigen (HBsAg) positive patient
Vinod Prabhu1, Aslam Shivani1, Avinash Patil1, Vishrabda Pawar2
1 Department of Surgery, Bharati Medical College, Sangli, Maharashtra, India
2 Department of Pathology, Bharati Medical College, Sangli, Maharashtra, India
|Date of Web Publication||30-Oct-2013|
"Shreyas", Behind Central Warehouse, Miraj, Sangli District - 416 410, Maharashtra
Pulmonary tuberculosis (TB) still forms a challenge in developing countries due to various forms of presentation, in spite of efforts taken by governments, non-governmental organisations (NGOs) and medical staff. Extrapulmonary TB is about 5% of all cases of TB, out of which perianal lesions constitute about 0.7%. The presence of hepatitis B surface antigen (HBsAg) positive disease with tuberculosis poses a challenge from both diseases, as regards the dilemma of treating the tubercular lesion with respect to hepatitis B surface antigen (HBsAg) positivity because of the compounding hepatotoxicity of anti-tubercular drugs and complications of cirrhosis and hepatocellular carcinoma. This is further complicated by a tuberculin test negativity, which in turn indicates a diminished immune status. This case report discusses a case of pulmonary and extrapulmonary (perianal) tuberculosis in a HBsAg positive patient.
Keywords: Hepatitis B surface antigen, perianal tuberculosis, tuberculin test
|How to cite this article:|
Prabhu V, Shivani A, Patil A, Pawar V. A rural medical college perspective for treating pulmonary and extrapulmonary tuberculosis in a hepatitis surface antigen (HBsAg) positive patient. J Health Spec 2013;1:138-40
|How to cite this URL:|
Prabhu V, Shivani A, Patil A, Pawar V. A rural medical college perspective for treating pulmonary and extrapulmonary tuberculosis in a hepatitis surface antigen (HBsAg) positive patient. J Health Spec [serial online] 2013 [cited 2020 Aug 13];1:138-40. Available from: http://www.thejhs.org/text.asp?2013/1/3/138/120853
| Introduction|| |
Pulmonary tuberculosis (TB) is a common disease in developing countries. Along with extrapulmonary TB, it assumes a disseminated form. This is aggravated by hepatitis B surface antigen (HBsAg) positivity which complicates the treatment. The patient needs to be monitored for deranged liver function while on drugs. Active surveillance is needed for these patients as they are at high risk of developing hepatocellular carcinoma and liver cirrhosis. This case attempts to discuss all these aspects.
| Case Report|| |
The presenting case was of a 60-year-old non-alcoholic male patient complaining of an ulcer near his anal opening for two months, which was painless with a colourless discharge. It was not associated with loss of weight, appetite, fever, cough with expectoration, or changed bowel habit. After visiting various clinics, he presented to us with the non-healing ulcer.
On examination, he had an ulcer in the perianal region 5 × 4 cm in size with pale granulation, seropurulent discharge and undermined edges [Figure 1]. There was no past history of perianal fistula nor was there any internal opening palpable or visible on proctoscopy. His blood count was normal. Erythrocyte sedimentation rate was 30 mm/hr, human immunodeficiency virus (HIV) was negative, liver function tests revealed (HBsAg) positive and alanine aminotransferase (ALT) 81 IU/L. Abdominal sonography was normal. Due to economic constraints the patient was unwilling for a colonoscopic exam and computed tomography (CT) abdomen. The magnetic resonance imaging (MRI) of the perianal region showed a small blind fistulous tract from the floor of the ulcer towards the anal canal, tuberculin test (TT) was 0 mm at 48 and 72 hours with no induration. Edge biopsy of the ulcer revealed TB [Figure 2].
|Figure 2: ZN staining showing tuberculous bacilli (TB) marked with arrow|
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The chest x-ray showed a tuberculous infiltration and the sputum was positive. Treatment by directly observed treatment with a four drug regime was initiated.
| Discussion|| |
TB is still a major health threat in the developing world as it still bears socioeconomic implications. Periorificial TB forms a small percentage of extrapulmonary TB and is rarely seen.  Pulmonary TB spreads to extrapulmonary sites like the perianal region due to swallowing of tuberculous infected sputum.  It can also occur as a result of hematogenous, lymphatic or direct spread of the disease. There are five types of perianal and anal tuberculous involvement, ulcerative, verrucous, lupoid and fissure-in-ano are all documented. 
Fistula is the most frequent lesion of anorectal and perianal TB and should be suspected in long standing and recurrent fistulae. Tuberculous fistulae are usually multiple, with pain, local swelling and anal discharge. 
This case was compounded by the fact that in spite of HIV negative status the TT was 0 mm indicating a very low level of cell mediated immunity and the patient was HBsAg positive posing a secondary challenge. There is a known increase in incidence of pulmonary TB in HBsAg positive cases.  Here, the ALT levels need to be examined because these levels decide whether the patient is to be categorised in active or inactive group, as the inactive group which has a normal ALT level (<40 IU/L) needs no active management and are labelled as Incidentally Detected Asymptomatic HBsAg Positive Subjects.  However, detecting levels of hepatitis B e antigen (HBeAg) is more indicative along with ALT levels but is cost restrictive in developing countries. The two important complications in HBsAg positive cases are hepatocellular carcinoma (HCC) and cirrhosis. A higher rate of cirrhosis occurs in HBeAg negative patients with raised ALT than HBeAg positive patients. Furthermore, HBeAg status does not predict the risk of HCC. Due to this uncertainty, ALT monitoring and regular follow-up form the mainstay of management in a developing country. This case had ALT levels >40 and hence required close follow-up.
The use of anti-tuberculous drugs also poses a challenge in HBsAg cases. Normal ALT levels permit the use of drugs with minimum complications as compared to raised ALT levels because this altered liver function makes hepatotoxicity of drugs a common complication that requires frequent monitoring of liver function when on anti-tuberculous treatment. 
Furthermore, the TT was negative indicating a low cell-mediated immunity. Patients with low cell-mediated immunity have been shown to have high carrier rates of HBsAg.  It is not unusual to have a negative TT as it indicates either a recent infection or an overwhelming infection. This case has been proven histologically and sputum positive for active infection and hence TT loses its significance but the reason for discussing this aspect of TT arises in latent tuberculosis wherein two-step testing is required. It has also been observed that TT reaction decreases with time even after bacille Calmette-Guerin immunization. If a second correctly administered and interpreted skin test is negative, then the individual does not have a TB infection, but a positive test indicates TB infection, the first test acting as an immunostimulant.
| Conclusion|| |
In cases of pulmonary and extrapulmonary TB occurring simultaneously and complicated by asymptomatic HBsAg positive cases, it is advisable to quantify enzyme ALT levels and start Anti Kochs Treatment (AKT) drugs, monitoring liver function every month to detect early hepatotoxicity in patients having raised ALT (> 40 IU/L). These patients need to be followed-up regularly for development of cirrhosis and HCC.
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[Figure 1], [Figure 2]