A Clinical Study on Risk Factors for Recurrent Pulmonary Tuberculosis – a Hospital-Based Study

  • Sabir Cholas Department of T.B and Chest Diseases, Kannur Medical College, Kannur, Kerala, India
  • Iftekhar Ahmed Nazeer Kannur Medical College, Kannur, Kerala, India
Keywords: Isoniazid, Recurrence, Rifampicin, Risk factors, Tuberculosis


Aim of the Study: The aim of this study was to understand and identify risk factors in recurrent cases of pulmonary tuberculosis
Materials and Methods: A total of 54 patients attending tertiary teaching hospital with recurrent pulmonary TB were included in
this study. Patients who were earlier cured using a four-drug treatment regimen of rifampicin, isoniazid, and pyrazinamide (RHZ)
were included in this study. The risk factors studied were age, gender, race, duration of symptoms, lesion cavitation, extent of
disease, diabetes mellitus (DM), alcoholism, HIV infection, delayed negative sputum conversion, treatment compliance, and
medication doses. To detect recurrence, the patients were monitored for 7.7 ± 2.0 years after cure. Data were analyzed using
the student’s t-test and the Chi-square test.
Observations and Results: A total of 54 patients with symptoms of recurrence of pulmonary TB were included in this study.
The mean age was 38.12 ± 4.60 years. There were 34 (62.96%) males and 21 (38.88%) females. The male-to-female ratio was
1.61:1. The mean age among the males was 40.09 ± 5.62, and it was 34.12 ± 3.75 years. The mean duration of the symptoms
was 82.45 ± 7.15 (12–238) days. There were 19 (35.18%) patients who were chronic alcoholics. The number of patients who
showed cavity in their X-ray lung investigation was 46/54 (85.18%). The noncompliance among the diabetic patients was
2/54 (3.70%) with the total number of patients with DM was 20/54 (37.03%). Among the 54 patients, 31/54 (57.40%) patients
were tested for HIV screening; among them, 07/31 (22.58%) tested positive for HIV. There were 07/31 (22.58%) positive HIV
test patients in the recurrence group, and 09.01% HIV positive incidence in the nonrecurrence group which was statistically
significant (P < 0.05).
Conclusions: Recurrence of TB was more common in HIV-positive patients, and in patients, who did not comply with the selfadministered treatment (RHZ regimen). Patients presenting at least one of these risk factors can benefit from the implementation
of a posttreatment surveillance system for early detection of recurrence. An alternative to prevent noncompliance with TB
treatment would be the use of supervised treatment.

Author Biographies

Sabir Cholas, Department of T.B and Chest Diseases, Kannur Medical College, Kannur, Kerala, India

Associate Professor, 

Iftekhar Ahmed Nazeer, Kannur Medical College, Kannur, Kerala, India

Associate Professor, Department of Pharmacology, 


1. Combs DL, O’Brien RJ, Geiter LJ. USPHS tuberculosis short-course
chemotherapy Trial 21: Effectiveness, toxicity, and acceptability. The report
of final results. Ann Intern Med 1990;112:397-406.
2. Perriëns JH, Colebunders RL, Karahunga C, Willame JC, Jeugmans J,
Kaboto M, et al. Increased mortality and tuberculosis treatment failure
rate among human immunodeficiency virus (HIV) seropositive compared
with HIV seronegative patients with pulmonary tuberculosis treated
with ‘standard’ chemotherapy in Kinshasa, Zaire. Am Rev Respir Dis
3. Hawken M, Nunn P, Gathua S, Brindle R, Godfrey-Faussett P, Githui W,
et al. Increased recurrence of tuberculosis in HIV-1-infected patients in
Kenya. Lancet 1993;342:332-7.
4. Mallory KF, Churchyard GJ, Kleinschmidt I, De Cock KM, Corbett EL.
The impact of HIV infection on recurrence of tuberculosis in South African
gold miners. Int J Tuberc Lung Dis 2000;4:455-62.
5. Fitzgerald DW, Desvarieux M, Severe P, Joseph P, Johnson WD Jr, Pape JW.
Effect of post-treatment isoniazid on prevention of recurrent tuberculosis in
HIV-1-infected individuals: A randomised trial. Lancet 2000;356:1470-4.
6. Driver CR, Munsiff SS, Li J, Kundamal N, Osahan SS. Relapse in
persons treated for drug-susceptible tuberculosis in a population with high
coinfection with human immunodeficiency virus in New York City. Clin
Infect Dis 2001;33:1762-9.
7. Korenromp EL, Scano F, Williams BG, Dye C, Nunn P. Effects of
human immunodeficiency virus infection on recurrence of tuberculosis
after rifampin-based treatment: An analytical review. Clin Infect Dis
8. Perriëns JH, St Louis ME, Mukadi YB, Brown C, Prignot J, Pouthier F,
et al. Pulmonary tuberculosis in HIV-infected patients in Zaire. A controlled
trial of treatment for either 6 or 12 months. N Engl J Med 1995;332:779-84.
9. Connolly C, Reid A, Davies G, Sturm W, McAdam KP, Wilkinson D.
Relapse and mortality among HIV-infected and uninfected patients withtuberculosis successfully treated with twice weekly directly observed
therapy in rural South Africa. AIDS 1999;13:1543-7.
10. Sterling TR, Alwood K, Gachuhi R, Coggin W, Blazes D, Bishai WR, et al.
Relapse rates after short-course (6-month) treatment of tuberculosis in HIVinfected and uninfected persons. AIDS 1999;13:1899-904.
11. Chaisson RE, Clermont HC, Holt EA, Cantave M, Johnson MP, Atkinson J,
et al. Six-month supervised intermittent tuberculosis therapy in Haitian
patients with and without HIV infection. Am J Respir Crit Care Med
12. Sonnenberg P, Murray J, Glynn JR, Shearer S, Kambashi B,
Godfrey-Faussett P. HIV-1 and recurrence, relapse, and reinfection of
tuberculosis after cure: A cohort study in South African mineworkers.
Lancet 2001;358:1687-93.
13. Lambert ML, Hasker E, Van Deun A, Roberfroid D, Boelaert M,
Van der Stuyft P. Recurrence in tuberculosis: Relapse or reinfection? Lancet
Infect Dis 2003;3:282-7.
14. Verver S, Warren RM, Beyers N, Richardson M, van der Spuy GD,
Borgdorff MW, et al. Rate of reinfection tuberculosis after successful
treatment is higher than rate of new tuberculosis. Am J Respir Crit Care
Med 2005;171:1430-5.
15. Jasmer RM, Bozeman L, Schwartzman K, Cave MD, Saukkonen JJ,
Metchock B, et al. Recurrent tuberculosis in the United States and Canada:
Relapse or reinfection? Am J Respir Crit Care Med 2004;170:1360-6.
16. de Boer AS, Borgdorff MW, Vynnycky E, Sebek MM, van Soolingen D.
Exogenous re-infection as a cause of recurrent tuberculosis in a lowincidence area. Int J Tuberc Lung Dis 2003;7:145-52.
17. Quy HT, Lan NT, Borgdorff MW, Grosset J, Linh PD, Tung LB, et al. Drugresistance among failure and relapse cases of tuberculosis: Is the standard
re-treatment regimen adequate? Int J Tuberc Lung Dis 2003;7:631-6.
18. Thomas A, Gopi PG, Santha T, Chandrasekaran V, Subramani R,
Selvakumar N, et al. Predictors of relapse among pulmonary tuberculosis
patients treated in a DOTS programme in South India. Int J Tuberc Lung
Dis 2005;9:556-61.
19. Petri WA Jr. Drugs used in the chemotherapy of tuberculosis,
Mycobacterium avium complex disease, and leprosy. In: Goodman LS,
Hardman JG, Limbird LE, Gilman AG, editors. Goodman and Gilman’s
the Pharmacological Basis of Therapeutics. New York: McGraw-Hill; 2001.
p. 1171-88.
20. Burman WJ, Cohn DL, Rietmeijer CA, Judson FN, Sbarbaro JA, Reves RR.
Noncompliance with directly observed therapy for tuberculosis. Epidemiology
and effect on the outcome of treatment. Chest 1997;111:1168-73.
21. Pulido F, Pena JM, Rubio R, Moreno S, Gonzalez J, Guijarro C, et al.
Relapse of tuberculosis after treatment in human immunodeficiency virusinfected patients. Arch Intern Med 1997;157:227-32.
22. Okwera A, Johnson JL, Luzze H, Nsubuga P, Kayanja H, Cohn DL, et al.
Comparison of intermittent ethambutol with rifampicin-based regimens in HIVinfected adults with PTB, Kampala. Int J Tuberc Lung Dis 2006;10:39-44.
23. Nettles RE, Mazo D, Alwood K, Gachuhi R, Maltas G, Wendel K, et al.
Risk factors for relapse and acquired rifamycin resistance after directly
observed tuberculosis treatment: A comparison by HIV serostatus and
rifamycin use. Clin Infect Dis 2004;38:731-6.
24. Badri M, Wilson D, Wood R. Effect of highly active antiretroviral therapy
on incidence of tuberculosis in South Africa: A cohort study. Lancet