|Year : 2014 | Volume
| Issue : 3 | Page : 162-165
Prevalence of tuberculosis: A study in forensic autopsies
Mitul M Sangma1, Thounaojam Meera Devi1, Babina Sarangthem2, Supriya Keisham1, Phurailatpam Madhubala Devi2
1 Department of Forensic Medicine and 1Pathology, Regional Institute of Medical Science, Imphal, India
2 Department of Pathology, Regional Institute of Medical Science, Imphal, India
|Date of Web Publication||5-Jan-2015|
Thounaojam Meera Devi
Department of Forensic Medicine, Regional Institute of Medical Sciences, Imphal - 795 004, Manipur
Source of Support: None, Conflict of Interest: None
Background: Tuberculosis is a major cause of morbidity and mortality in developing countries. There are many cases of tuberculosis which remain undiagnosed and are diagnosed only at autopsy. Materials and Methods: This retrospective study was conducted on cases brought for forensic autopsy in a tertiary care medical centre from the year 2003 to 2012. The history, post-mortem findings, and histopathological findings of the cases were meticulously studied and analyzed. Results: Out of the total 4,415 autopsies, 74 cases had findings of tuberculosis. Males outnumbered females, and the highest number of tuberculosis cases was observed in males in the age-groups of 40 to 50 years (32.43%) followed 50 years and above (25.67%). Tuberculosis as to be the primary cause of death was observed in 28.38% of the cases, of which 22.97% were pulmonary while 5.41% were cases of disseminated/extrapulmonary tuberculosis. In the lung, active tuberculosis was observed in 34.28%, i.e., granulomatous inflammation with caseation necrosis (27.14%) or granulomatous inflammation with caseation necrosis and tubercular pneumonia (7.14%). Suspicious cases of inactive tuberculosis, i.e., fibrosis and calcification was observed in 65.71% of the cases. Conclusion: The chance finding of tuberculosis in forensic autopsy cases in this study highlights that there are undiagnosed cases of active tuberculosis who are not seeking proper medical attention and these cases may pose as a source of transmission to the general public, health-care providers and mortuary staff.
Keywords: Forensic autopsy, Tuberculosis, Active, Inactive, Infection, Mortuary staff
|How to cite this article:|
Sangma MM, Devi TM, Sarangthem B, Keisham S, Devi PM. Prevalence of tuberculosis: A study in forensic autopsies. J Med Soc 2014;28:162-5
| Introduction|| |
Tuberculosis (TB) is a major global health problem and the burden of the TB is highest in Asia and Africa. India and China account for 26% and 12% of global cases, respectively.  In developed countries, the morbidity and mortality associated with TB has decreased, whereas it is still in a problem in developing countries. Most cases of TB are pulmonary and acquired by person to person transmission of air-borne droplets of organisms.  In forensic practice, most of the cases brought for post-mortem examination are of unknown background with unknown history and as such the risks of infection from these bodies do exist. It is a known fact that autopsy is an exceptionally efficient method of transmitting TB from the dead body to those present in the autopsy room. The risk of infection does not vary with distance from the autopsy table. Exposures as brief as 10 minutes in the autopsy room have resulted in transmission.  At the same time, it has been documented that autopsy exposure is far more infectious than exposure during life and it is not unusual for TB to remain undetected until a patient dies.  The present study has been taken up to find out the prevalence of TB in forensic autopsy cases in this centre.
| Materials and Methods|| |
This retrospective study was conducted on the cases brought for forensic autopsy in a tertiary health care centre at Imphal during the period of 10 years, i.e., from the year 2003 to 2012. A detailed history of the cases, the age, sex, cause of death, and type and extent of TB observed during autopsy were recorded. The tissues which showed gross findings during autopsy were sent for histhopathological examination. The TB cases were classified into those having active TB and suspicious cases of inactive TB. Active TB was defined as those cases with granulomatous inflammation with caseation necrosis on examination of the tissue samples stained with haematoxylin and eosin (H and E) stain; and suspicious cases of inactive TB was defined as cases with fibrosis and calcification of the lung. The post-mortem findings and histopathological findings were recorded and analyzed.
| Results|| |
It is observed from [Figure 1] that out of the total 4,415 autopsy cases, 74 cases (1.7%) had findings of TB. In the year 2003, 1.49% of the cases had findings of TB; however, slight increase in the total number of TB cases was observed during the years 2010 and 2011, i.e., 2.75% and 3.19% of the cases, respectively [Table 1]. Males outnumbered females and the highest number of TB cases was observed in males in the age groups of 40 to 50 years (32.43%) followed 50 years and above (25.67%) as shown in [Table 2]. TB as to be the primary cause of death was observed in 28.38% of the cases, of which 22.97% were pulmonary while 5.41% were cases of disseminated/extrapulmonary TB [Table 3]. In the lung, active TB was observed in 34.28% [Table 4] i.e., granulomatous inflammation with caseation necrosis (27.14%) [Figure 2], or granulomatous inflammation with caseation necrosis and tubercular pneumonia (7.14%) [Figure 3]. Disseminated/extrapulmonary TB involving spleen and kidney are shown in [Figure 4] and [Figure 5]. Suspicious cases of inactive TB, i.e., fibrosis and calcification were observed in 65.71%.
|Figure 2 : Photomicrograph showing caseating tubercular granuloma in the lung hematoxylin and eosin (H and E) stain (×100)|
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|Figure 3 : Photomicrograph showing tubercular pneumonic consolidation with caseating necrosis hematoxylin and eosin (H and E) stain (×100)|
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|Figure 4 : Photomicrograph showing caseation necrosis, Langhans' giant cell in spleen hematoxylin and eosin (H and E) stain (×400) disseminated tuberculosis (TB)|
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|Figure 5 : Photomicrograph showing caseation necrosis in the kidney hematoxylin and eosin (H and E) stain (×100) disseminated tuberculosis (TB)|
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| Discussion|| |
TB is an infectious disease caused by the bacillus mycobacterium tuberculosis. It typically affects the lungs (pulmonary) but can affect other sites as well (extrapulmonary). Several studies have shown that many cases of TB were diagnosed at autopsy. In a study by Adrion et al., and Lun and Koelmenger,  it was found that the frequency of active TB was 1.9% and that 70% of those cases were diagnosed only at autopsy. In our study, 1.7% of the cases had TB and these cases were diagnosed only during autopsy. TB cases are reported to have been declined across the world. However, in the present study, a slight increase in the number of cases of TB could be observed during the years 2010 and 2012.
In a study by Pavic et al.,  clinically unrecognized active TB occurred more often in men than women, especially in younger age-groups, and this may reflect everyday life habits, especially consumption of tobacco and alcohol, or difficult job conditions such as working outdoors or in poorly ventilated spaces. However, according to a study by Garg M,  active TB today is a disease of elderly and is attributable mainly to recurrence of dormant infection and decrease in immune status of elderly. This holds true in the present study as most of the cases belonged to the older age group. In India, out of the 300 million people infected with mycobacterium TB, 12 million are constituted by cases with active TB.  In our study, active TB was observed in 34.28%, i.e., granulomatous inflammation with caseation necrosis (27.14%) or granulomatous inflammation with caseation necrosis and tubercular pneumonia (7.14%). Although TB can affect any organ, 70-80% cases suffer from pulmonary TB.  In the present study, 22.97% of the cases had pulmonary TB as the primary cause of death while 5.41% of the cases died due to disseminated/extrapulmonary TB.
Social stigma often discourages people from seeking treatment and, thus, undiagnosed TB cases form a substantial proportion of cases reported in autopsy studies.  This indicates that there are people who do not seek medical attention and these cases pose as threat to the medical workers and mortuary staff. In forensic practice, most of the cases are brought without any known history and the danger of transmission of such diseases to the mortuary workers is high. The group at higher risk include autopsy workers and persons involved in histopathological preparation from fresh materials.  Moreover, most of the mortuary staffs do not understand the problem of bacterial contamination of the autopsy room and they face dangers of exposure to such risks. Staffs of laboratories and autopsy rooms are estimated to be between 100 and 200 times more likely than the general public to develop TB.  Instances of TB outbreaks caused by multidrug resistant mycobacterium TB have increased in the recent past  and this is indeed a matter of concern for autopsy workers.
| Conclusion|| |
The finding of TB in forensic autopsy cases in this study highlights that there are undiagnosed cases of active TB who are not seeking proper medical attention and these cases may pose as a source of transmission to the general public, health-care providers, and mortuary staff. Mortuary staffs should be made aware of the existing problem in order to minimize these dangers. A strict implementation of safe procedure for high-risk autopsies is highly recommended.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4]