Transworld Medical JournalAvailable online at www.tmjournals.comOriginal Research PaperPulmonary Tuberculosis and its hematological correlatesPravat Kumar Thatoi,* Sagar KhadangaDepartment of Medicine, SCB Medical College, OdishaAbstractBackground: There is a paucity of literature in the hematological changes associated with tuberculosis.Aims: To evaluate the hematological parameters in pulmonary tuberculosis patients.Methods and Materials: One hundred patients of pulmonary tuberculosis with sputum positive for acid fast bacilli (AFB) were studied for various hematological parameters by means of hemogram by automated cell counter and peripheral smear examination.Results: Anemia was seen in 74% of patients; 71% had a normal leukocyte count. Leucocytosis as a response to infection was observed in 26 patients. Three had leucopenia. Thrombocytosis was observed in 24 while thrombocytopenia was observed in 9. 99% patients had increased erythrocyte sedimentation rate (ESR). Two patients had pancytopenia.Conclusions: While many of the haematological traits such as anemia and increased ESR are consistent with reported literature and reinforce the fact that they can be valuable tools in monitoring pulmonary tuberculosis. Other findings such as thrombocytosis and pancytopenia suggest the need for further research in this field.Keywords: Pulmonary tuberculosis, anemia, leucocytosis, thrombocytosis, pancytopenia.IntroductionTuberculosis (TB) is a highly prevalent chronic infectious disease caused by Mycobacterium tuberculosis bacilli. Globally, TB remains at an epidemic level affecting one third of world population.1 About one third of India population are infected with it. The emergence of human immunodeficiency virus (HIV) infection has made the situation worse.2 Around 10% of TB cases are in the first and second decade of life. It affects three times as many men as women.3Reversible peripheral blood abnormalities are commonly associated with pulmonary TB. Insight into the relationship between hematological abnormalities and mycobacterial infection has come from an understanding of the immunologyTel.: +91 9437170150Email: drpravatthatoi@yahoo.co.in, Transworld Medical Journal. All rights reserved. of mycobacterial infection. Little is known about the prevalence of these hematological abnormalities and the effect of antituberculosis treatment on the various hematological parameters in the Indian subcontinent.4This study was undertaken to analyse the hematological parameters in patients with sputum smear positive for AFB and to evaluate their diagnostic and prognostic significance.Materials and methodsDuring a period from Jan 2012 to Dec 2012, hematological parameters were studied in pulmonary tuberculosis patients whose sputum was positive for AFB. The blood cell counts were analyzed using fully automated hematology analyzer Sysmex KX 21, using EDTA anticoagulated fresh venous blood sample.Thatoi PK / Transworld Medical Journal 1(1) 1113All patients had a detailed hemogram including hemoglobin (Hb), total leukocyte count (TLC), differential leukocyte count (DLC), platelet count, hematocrit (HCT), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), erythrocyte sedimentation rate (ESR), and peripheral blood smear (PS) to study the RBC and WBC morphology. The data were entered in Excel chart and analyzed. Descriptive statistics were used for the analysis.ResultsOf the 100 subjects there were 71 males and 29 females with mean age of 41 years. Mean age for males was 42 years and mean age for females was 35 years.In males, the Hb value ranged from 6.9g/dl to 16.3 g/dl with the mean being 11.5 g/dl. In females, the mean Hb level was 10g/dl ranging from 7.1g/dl to 14.4g/dl. In 28% cases Hb was less than 10gm/dl. (Table 1)The definition of anemia used in this study was hemoglobin concentration less than 13g/dl in men and 12 g/dl in women.5 Anemia was typed based on the MCV, MCH and peripheral smear findings. Anemia was present in 74 patients. Normocytic anemia was the most common type and was found in 49 (66.2%) patients. Microcytic anemia was next common type and was seen in 22 patients. Three patients had macrocytic anemia in which the MCV was more than 100 fl.In spite of the infection, 71 patients had a normal leucocyte count. Lecocytosis as a response to infection was observed in 26 patients of which 21(80.7%) were males and 5 (19.3%) were females. All patients with leucocytosis had neutrophilia. Three patients had leucopenia.Thrombocytosis was observed in 24 patients while thrombocytopenia was observed in 9 patients. Interestingly thromobocytosis was observed in patients who had leucocytosis.99% of patient had increased ESR. Only one patient had a normal ESR. 13 patients had ESR ranging from 20 to 40 mm in first hour, 30 patients had ESR in the range of 40 60 mm, 35 had from 60 to 80 mm and 11 patients had ESR value more than 100 mm.12 Table-1. Haematological profileTotalHb (Gm/dL)No (%)1412Total100Anaemia74Normocytis anaemia49Microcytic anaemia22Macrocytic anaemia3Leucocytosis26Thrombocytosis with leucocytosis24Leucopenia9Increased ESR99ESR (2040) in first hr13ESR (4060) in first hr30ESR (6080) in first hr35ESR ( more than 80) in first hr11DiscussionThe present study had been an attempt to study a complete hematological profile in pulmonary TB. The prevalence of anemia and its types in the present study was similar to the other studies.2,5,6 Various researches have reported a blunted erythropoietin response to anemia of untreated tuberculosis. It is postulated that the tumor necrosis factor (TNF- ) and other cytokines released by activated monocytes suppress the erythropoietin production leading to anemia.2 The incidence of macrocytic blood picture is similar to a study done by Morris et al.6Leucocyte response varied from leucocytosis to pancytopenia. Mild leucocytosis is documented in 8-40% of patients with pulmonary tuberculosis.3 The prevalence of leucocytosis in present study was similar to study done by Singh KJ et al.2 Although, changes were reported in relative number of the WBCs, these had not proved useful either as clinical or prognostic value. 7The reported prevalence of leucopenia in pulmonary tuberculosis is 1-4%.8 The results of present study are in agreement with these studies. Neutropenia was the predominant finding in these patients, which may be a consequence of the combined effect of hypersplenism, excessiveThatoi PK / Transworld Medical Journal 1(1) 1113margination of neutrophil or marrow granulopoietic failure mediated by the T-lymphocyte showing granulopoietic inhibitor activity. Many authors reported lymphocytopenia in patients with pulmonary TB. The exact reason for the development of lymphocytopenia has not been elucidated. Nevertheless, the role of cytokine including TNF in the pathogenesis of lymphocytopenia has been suggested.2Previous studies have documented pancytopenia in patient with disseminated and military TB and but it is a rare finding in patients with pulmonary TB.8 In the present study two cases had pancytopenia and bone marrow examination could not be done as the patients were not willing for further evaluation. Thrombocytosis has been reported in patients with military or disseminated TB.6,8 In our study, 26% had thrombocytosis, which is close to the findings of Singh KJ et al.2 Various inflammatory cells, cytokines and mediators are involved in the formation of granulomatous lesions encountered in tuberculosis. Among them interleukin-6 (IL-6) has been known to promote platelet production.9Studies reported on the value of the ESR as a test of activity in pulmonary TB have concluded that it is an useful practical method of obtaining dependable information about the actual progress or retrogression of tuberculous lesion, before these can be demonstrated by other clinical and laboratory procedures. Previous studies have documented an elevated ESR level in majority of patients which decreased significantly in those who sputum becomes negative. 99% of patients with increased ESR in the present study are in concordance with the reported literature. 1 ReferencesOliva VM, Cezario GAC, Cacto RA et al. Pulmonary tuberculosis; haemotology, serum biochemistry and relationship with the disease condition. J Venom Anim Toxins Incl Trop Dis 2008;14:71-8. Singh KJ, Ahulwalia G. Sharma SK, Saxena R, Chaudhary VP, Anant M. Significance of hematological manifestations in patients with tuberculosis, J Asso Physicians Ind 2001; 49:788-94. Goldenberg AS. Hematologic abnormalities and mycobacterial infection. In, Williams NR, Stuart GM (ed). Tuberculosis. Boston, Little Brown Company, 1996;645-7. Vijayan VK, Das S. Pulmonary tuberculosis. In: Suredra Sharma (ed). Tuberculosis 1st edition. New Delhi, Jaypee Publishers, 2009; 217-27. 5.Lee SW, Kang YA, Yoon YS, et al. The prevalence and evolution of anemia associate with tuberculosis. J Korean Med Sci 2006;21:1028-32. Morris CD, Bird AR, Nell H. The hematological and biochemical changes in severe pulmonary tuberculosis. Q J Med 1989;73:1151-9. Tanzeela T, Bashir MB, Yaqoob M. Comparative efficacy of different laboratory technique used in diagnosis of tuberculosis in human population. J Med Sci 2001;2:137-44. Maartens G, Willcox PA, Benatar SR. Miliary tuberculosis: rapid diagnosis, hematologic abnormalities and outcome in 109 treated adults. Am J Med 1990;89:291-6. Kartaloglu Z, Cerrahoglu K, Okutan O, Ozturk A, Aydilek R. Parameters Of Blood Coagulation In Patients With Pulmonary Tuberculosis. The Internet Journal of Internal Medicine 2001; 2(2). Accessed on 3rd October 2011. ConclusionThis study has shown that anemia was frequently encountered in patients with pulmonary TB and normocytic normochromic anemia was the most common type. Thrombocytosis, leucocytosis, leucopenia with neutropenia and lymphocytopenia was observed in various proportions. These findings reinforce the fact that they can be valuable tools in monitoring such patients. Other findings such as thrombocytosis and pancytopenia suggest the need for further studies in this field. Cite this article: Thatoi PK. Pulmonary tuberculosis and its haematological correlates. Transworld Medical Journal. 2013;1(1):11-1313