The Challenge of Extrapulmonary Tuberculosis (EPTB)

Context

The public health issue posed by extrapulmonary TB (EPTB) may exceed the current assessments of Tuberculosis in India.

Tuberculosis Infections

• Non-Pulmonary Tuberculosis Infections: While pulmonary TB, affecting the lungs, is the most common form of tuberculosis (TB) infecting the lungs. However, around 20% of TB infections develop in the lymph nodes, brain, gut, eyes, or other organs. 
• Underestimation of TB Infections: Similar to the underestimation of individuals infected with TB, the public health issue posed by extra-pulmonary TB (EPTB) may exceed our current assessments.
  • The World Health Organization (WHO) reports over 10 million new cases of TB every year and India alone accounts for 27% of the global TB burden. 

Enroll now for UPSC Online Course

Extrapulmonary Tuberculosis (EPTB)

Extrapulmonary Tuberculosis is tuberculosis outside of the lungs.

• EPTB includes tuberculosis meningitis, abdominal tuberculosis (usually with ascites), skeletal tuberculosis, Pott’s disease (spine), scrofula (lymphadenitis), and genitourinary (renal) tuberculosis. 

Challenge with Extra-pulmonary TB (EPTB):

• Diagnostic Challenge: The burden of Extrapulmonary Tuberculosis is hard to estimate. EPTB is often stain-negative i.e., it is not detectable on regular TB stain tests. 

• • The infection may surface in any part of the body and present itself like other non-TB conditions. Many cases of EPTB may not have a corresponding lung infection. 
  • So, EPTB’s true prevalence in society remains hidden.
• Impact of TB Underdiagnosis: The underdiagnosis of EPTB leads to irreversible damage to infected organs, potentially resulting in complications such as vision loss or blindness. 
  • Hence, it is imperative to address tuberculosis comprehensively, acknowledging its various complexities.
• Knowledge Silos in Extrapulmonary Tuberculosis (EPTB) Management: As TB can be present in multiple organs, the lack of formal and functioning protocols to exchange information between doctors in multiple specialities leads to silos of knowledge. 
• Infection Spread and Organ Interactions: Key aspects of EPTB, including the mechanisms of infection spread and the TB bacterium’s interactions with our organs, remain under-explored. 
• Persistent Disease Markers in EPTB: A troubling aspect of EPTB infection is the prolonged presence of disease markers even after the infection is resolved with treatment.
  • Some EPTB patients who complete anti-TB therapy may still find themselves affected by the disease. 
  • For example, In the eye, an autoimmune response to antigens triggered by the original infection can lead to persistent intraocular inflammation even after appropriate anti-TB therapy. 
• Immunological Persistence: There could be additional immunological mechanisms at play in other organs impacted by Extrapulmonary Tuberculosis, potentially extending the duration of the disease even after the bacteria have been eradicated from those organs. 
  • This occurrence results in considerable distress for individuals with EPTB and represents a focal point of ongoing research.

Way Forward

• Common Approach to Extrapulmonary Tuberculosis Management: It needs to be done to be fostered, especially in a high TB burden country like India.
• Enhancing Data Collection: Equipped with guidelines and practice points, the hospital systems need to generate better data on EPTB. 
  • Presently, EPTB statistics primarily rely on the TB departments of major public hospitals.
  • Specialist departments for each organ are the primary centres forExtrapulmonary Tuberculosis management. Their data practices are diverse and do not become part of the aggregate numbers for Extrapulmonary Tuberculosis prevalence. 
    • These departments must capture patient data and share it with the National TB Control Programme. 
    • Their action may help reinvigorate Ni-kshay, the national patient management portal for TB control, which has incomplete and missing data on TB patients insofar as EPTB patient data are concerned.

• Unraveling Immune Mechanisms in Extrapulmonary Tuberculosis:  Collaborative efforts across various EPTB specialties, coupled with the utilization of advanced immunological tools like single-cell RNA sequencing, hold promise for explaining the immune mechanisms underlying the disease. 
  • Without a thorough understanding of these mechanisms, physicians may persist in administering prolonged courses of anti-TB therapy under the assumption that the infection persists within the organ. 
  • However, this approach not only proves ineffective in resolving the disease but also subjects the patient to the prolonged anti-TB therapy.
• Updating INDEX-TB guidelines: The INDEX-TB guidelines require updating based on the most recent data and experience as they were developed more than ten years ago. 
  • Additionally, they must be multidisciplinary and gain from the contributions of several specialized health care fields.
• Establishing Diagnostic and Therapeutic Protocols for Extrapulmonary Tuberculosis: There are no established diagnostic or therapeutic procedures for all organs impacted by EPTB. To formulate them, high-quality data from clinical trials will be required.

Enroll now for UPSC Online Classes