Open Access Research Journal Medical and Health Science Journal, MHSJ

www.academicpublishingplatforms.com ISSN: 1804-1884 (Print) 1805-5014 (Online) Volume 6, 2011, pp. 75-81

EPIDEMIOLOGICAL AND DIAGNOSTIC ASPECTS OF

OSTEOARTICULAR TUBERCULOSIS IN CHILDREN AND
ADOLESCENTS IN KAZAKHSTAN

The paper presents updated epidemiological data LAYLA AMANZHOLOVA

on osteoarticular tuberculosis (OAT) among
children and adolescents in Kazakhstan during NATIONAL CENTER FOR TB
1995-2007. Retrospective analysis of methods of PROBLEMS KAZAKHSTAN
detection, risk factors for disease development
and frequency of mistaken diagnosis among 248
children and adolescents was conducted. Our
investigation revealed that during 2006-2007
decrease in OAT incidence was noted among
children and adolescents. Phthisiatric methods
allowed to verify the OAT diagnosis in 272.8% of
cases, roengenological ones - in 69.42.9%
(<0.05), surgical biopsy method - in 17.92%;
diagnosis of OAT was verified in 72.52.4% of
cases at addressing of relatives of a patient.
Keywords: Extrapulmonary tuberculosis, osteoarticular tuberculosis, children and adolescents.
UDC: 616.71/.72-002.5-053.2-036.22-07 (574)

Introduction

Extrapulmonary tuberculosis is an integral part of tuberculosis

issue. Before this issue concerning to the children was studied by
Kulchavenya (1992), Aksenova and Senjkina (2001). Mushkin
(2008), Serdobintzev and Olejnik (2008) suggest that compared with
other extrapulmonary locations, osteoarticular tuberculosis is the
leading cause of primary invalidization which scales up to the level
of 87.5%. Kulchavenya (1992), Yuldashov (2004), Mushkin and
Kovalenko (2006) note that the extrapulmonary tuberculosis is
enable to injure all organs and tissues including osteo-articular
system, and nowadays it remains the prevalent disease.
Serdobintzev and Olejnik (2008), Khafizov et al. (2008) regarding
the problems of diagnostics and treatment of osteoarticular TB
prove that the availability of modern diagnostic technologies and
methods for verification of this pathology differs. Invasive methods
are implemented rather rare despite of their informativity which
reaches up to 90%.
Aim of this study is to determine the epidemiological significance of
osteoarticular tuberculosis (OAT) among children and adolescents
under present conditions and to study the possibilities for diagnostic
verification of this disease in the country.
Materials and methods

Epidemiological indicators of OAT prevalence were studied during

1995-2007 on the base of the statistical data and electronic register
all over the country. Retrospective analysis was conducted on study
of diagnostic methods, causes of untimely diagnosis and OAT
development risk factors in 248 patients treated during 1995 to
2007 at the National Center for TB Problems and Sanatorium for
patients with bone-and-joint TB from South Kazakhstan oblast.
To process the clinical material we used the methods of statistical
analysis with finding of the average error of difference, confidence
interval. Difference is significant if P<0.05 and P<0.01; and it is not
significant when P>0.05. To determine the statistical significance of
compared sets (signs) the Pearson 2 criterion at the level of
significance P<0.05 was used.

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Results and discussion

Nowadays TB incidence among children population in the country is

presented by pulmonary form; share of extrapulmonary TB (ETB)
decreased in the incidence structure by more than 2 times (from
14.8% to 7%) during the observed period. As it is seen in the Figure
1, during 1995-1999 the percentage of extrapulmonary TB among
children and adolescents tended to increase by 1.5 times (from
10.5% to 14.8%); then after some stabilization it had been
decreasing since 2005 falling to 7%. Among newly detected children
with TB the percentage of extrapulmonary TB did not exceed 10% to
14%. Thus, in the general TB incidence among children and
adolescents population in the country the extrapulmonary TB keeps
sufficiently modest level, since tuberculosis of breathing organs was
predominant during all observed period.
Figure 1 shows that in the structure of children with ETB the first
place belongs to the tuberculosis of lymphatic nodes (TBLN) (from
41.2% to 46.7%), with followed OAT (from 20.3 to 28.8%) and ocular
TB (from 3.7 to 13.5%). These data correspond to the results of
Wang (2007) who noted the prevalence of TBLN and OAT in Taiwan
during 1998-2005.
The country analysis of TB incidence by years indicated the
statistically reliable decrease in percentage of children with TB of
CNS (from 10.4% to 1.1%; P<0.01), TB of urogenital system (from
7.9% to 2.0%; P<0.01) and OAT (from 28.8% to 20.3%; P<0.05).
Frequency of registration of other remained TB forms varied
insignificantly and was statistically unreliable (Table 1).
OAT incidence increased since 1997 (Figure 2) from 1 to 2.2 per
100.000 of children, while during 2002-2007 it tended to decrease
from 1.4 to 0.6. Also, over 1995-2000 the increase of this indicator
was marked among adolescents (from 1.8 to 2.2 per 100.000);
during 2001-2007 it decreased from 1.9 to 0.9. Our epidemiological
indicators coincide with observation of Bezuglaya (2004).
The total number of children and adolescents with OAT included in
the statistical data and electronic registers during 1995-2007 in the
country are presented in the Table 2. The figure constituted 777
patients, i.e. 22% out of all patients newly detected with OAT (3531)
during this period. Analysis of the age and gender composition of
newly detected children and adolescents with OAT during 1995-
2007 showed that the males made 57.9% (450), females - 42.1%
(327). In the age structure of the studied children the school age
children of 8-14 years old were prevailed (42.72%).
Figure 3 shows the incidence depending on gender among children
and adolescents with firstly developed OAT during the period 1995-
2007. Prevalence of males (06-0.9 per 100.000 among population of
children and adolescents) compared with females is clearly marked.
This trend is also marked in the work of Bezuglaya (2004), where
also OAT disease occurred among boys more frequently than among
girls.
Among children and adolescents the rural inhabitants are prevalent
(62.4%6.1): it obviously can be explained by unfavorable social
and living conditions, and population migration. Thus, urban
inhabitants constituted 37.6%5.2 (0.005).
During the observed period different forms of OAT occurred (Figure
4). Since 2002 among clinical forms of OAT increase in number of
children with limited osteitis and OAT of other locations is observed.
For the last years they have constituted 13.9% out of all operated
patients on average. On the other hand, number of children with
spondylitis and with its complications, such as the skeletal
deformations, decreased by nearly 2 times.
To study the possibility of verification of OAT diagnosis in 248
children and adolescents operated during 1995-2007 there were
studied the disease durability, terms of examinations and frequency
of mistaken diagnoses. During this time patients were under
observation according to their place of residence and received the
nonspecific therapy. As the Table 3 shows, period of diagnosis
statement in patients with OAT constituted up to 6 months in
39.13.1%, up to 1 year in 36.33.1% (P<0.05) cases. Children and
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adolescents (10.92%), in which TB process of the skeletal system

was diagnosed after 1 year of disease, constituted notable small
percentage.
In the stage of observation, before OAT diagnosis statement,
patients were treated from other diseases in the primary healthcare
network. Table 4 indicates that patients received the treatment
mostly were wrongly diagnosed with osteomyelitis and arthritis.
These particular mistakes are due to the common signs of the main
disease and nonspecific injuries of a skeleton. In the stage of
observation diagnosis was not stated due to the difficulties of
differential diagnostics of the skeletic system in 212.6%. The
similar observations were noted by Kovalenko (2003), Mushkin
(2004), Bezuglaya (2005), Hadadi et al. (2010).
It should be noted that from all patients examined in the stage of
observation 66 (27.02.9%) patients were operated. Opening of the
formations in the area of injured skeleton which were valued as the
suppurative processes in the soft tissues was performed without
following histological or pathological material bacteriological
verification. Further, this incorrect physician diagnostic tactics
complicated the disease course and conditioned formation of
fistulae in 5 (2%) cases; and observed duration of fistula closing
constituted from 6 months to 2 years.
As our investigation shows, diagnosis of OAT was verified by well-
known methods in 272.8% out of 248 children and adolescents,
including roentgenological investigations of a skeleton in 69.32.9%
(<0.05), and surgical biopsy in 17.32.4%.
Analysis of clinical material and disease anamnesis found familial or
relative TB contact in 40.7% (101) of patients; the poor
socioeconomic conditions in 26.6% (66); single parent families,
orphanage in 10.4% (26); family migrant status in 12.5% (31).
Above mentioned risk factors influenced durability of the period of
diagnosis statement and disease development.
The poly-factorial analysis indicated that such risk factors as the
contact (2=196.2), mistakes in diagnosing (2=173.3), and social
status (2=182.9) are statistically significant for OAT disease
development: they take three rating places. The most important risk
factors proper to children with OAT are also the contact (2=188.7),
then trauma (2=179.6) and mistakes in diagnosing (2=167.5).
Analysis of epidemiological and diagnostic aspects of ETB, including
OAT in children and adolescents in Kazakhstan allows to note the
changes occurred in the last years. Important positive factors
during 2006-2007 include the shortening of diagnosis statement
period up to 3-6 months, decrease in TB incidence rate and in the
number of complications including the skeleton deformations. These
achievements were provided by implementation of WHO strategy
since 1999 as well as carrying out of the National TB Program,
further improving of the methods of general prevention, increasing
in number of children isolated from TB sources with positive sputum
smear, and improving knowledge in TB of physicians. Beside this,
wide implementation of modern methods of roentgenological
examinations (computer and MRI tomography) regarding to the
osteoarticular TB in children contributed to the decrease in OAT
indicators.
Conclusion
During the period of investigation the percentage of extrapulmonary
tuberculosis among children and adolescents decreased by more
than 2 times (from 14.8% to 7%); while prevalence of TB of
breathing organs is observed during the whole observed period. In
the structure of extrapulmonary tuberculosis TBLN takes the first
place, OAT and ocular TB are following. Decrease in TB incidence
among children (from 1.4 to 0.6 per 100.000) and adolescents (from
2.2 to 0.9 per 100.000) of children and adolescent population was
noted.
As our investigation shows, diagnosis of OAT was verified by
wellknown methods in 27.02.8% out of 248 children and
adolescents, including roentgenological investigations of a skeleton
in 69.32.9% (P<0.05), and surgical biopsy in 17.32.4%. Analysis
of the
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epidemiological and diagnostic aspects of extrapulmonary TB,

including OAT in children and adolescents during 2006-2007 allows
to pay attention to the positive factors appearead such as the
decrease in TB incidence rate, shortening in terms of OAT diagnosis
statement in children before 3-6 months, decrease in number of
complications including the rough skeleton deformations.
References

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in Russia (epidemiology, clinical forms and their observation), Journal
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krae], in Russian, Synopsis of doctoral dissertation, Russia, Vladivostok.
Hadadi A, Rasoulinejad M, Khashayar P, Mosavi M, Maghighi Morad, M., 2010.
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organic tuberculosis, In: Levashov, Yu. And Mushkin, A. (Eds.), Works of the
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Nauchnye trudy Vserossiyskoj nauchno-prakticheskoj konferenzii], Sankt-
Peterburg, pp.291-292.
Kulchavenja, E., Zhukova, I., 1992. Extrapulmonary tuberculosis in children,
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Serdobintzev, M., Olejnik, V., 2008 Problems of diagnostics and surgical treatment
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Mushkin, A. (Eds), Works of the Russian scientific-and-practical conference
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prakticheskoj konferenzii], Sankt-Peterburg, pp. 234-235.
Wang, P., 2008. Epidemiological trends of childhood tuberculosis in Taiwan, 1998-
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Appendix

TABLE 1. STRUCTURE OF PATIENTS WITH OAT AMONG CHILDREN DURING 1995-2007 (%)

OAT 1995 1997 1999 2001 2003 2005 2007

TB of central nervous system (CNS) 5.3 6.7 8.9 9.1 10.4 9.8 6.1
Osteoarticular tuberculosis (OAT) 34 33.0 22.7 28.1 28.8 31.4 20.3
Urogenital tuberculosis (UGT) 7.9 6.7 5.5 8.2 4.4 4.6 2
Tuberculosis of peripheral lymphatc nodes (TPLN) 41.2 43.5 4.7 37.5 41.2 40.2 42.6
Ocular tuberculosis (OT) 6.8 4.2 3.7 7.3 7.6 6.9 13.5

TABLE 2. AGE AND GENDER CHARACTERISTICS OF NEWLY DETECTED CHILDREN

AND ADOLESCENTS WITH OAT OVER 1995-2007 (ABS.)

Age (years) Gender

Boys Girls
abs. %m abs. %m abs. %m
0-7 253 32.61.7 145 18.71.4* 108 13.91.2
8-14 332 42.71.8 183 23.61.5* 149 19.21.4
15-17 192 24.71.5 122 15.71.3* 70 91.0
777 100.0 450 57.91.8* 327 42.11.8
Note: * Reliable difference with group of girls, <0.05.

TABLE 3. DURATION OF DISEASE IN CHILDREN AND ADOLESCENTS WITH DIFFERENT FORMS OF OAT

Clinical groups Duration of disease

Up to 3 months Up to 6 months Up to 1 year 1.5-2 years
abs % abs % abs % abs %
I.TB spondylitis n=148 28 11.32 45 18.12.4* 54 21.82.6* 12 4.81.4* ^
II.TB of major bones and joints 14 5.61.5 21 8.51.8 25 10.11.9 10 41.2
(coxitis and gonitis), n=50 ^
III.TB osteitis, n=50 9 3.61.2 31 12.52.1* 11 4.41.3 5 20.9 ^
Total, n=248 51 20.62.6 97 39.13.1* 90 36,33.1* 27 10.92* ^
Notes: * - Reliable difference with group up to 3 months, <0.05; ^ - reliable difference with different groups, <0.01.

TABLE 4. DIAGNOSES IN PATIENTS WITH OAT IN THE STAGE OF TREATMENT IN PHC

Nosology I ., n=148 II ., n=50 III ., n=50 Total, n=248

abs % abs % abs % abs %
Osteomyelitis 4 1.60.8 6 2.41 5 20.9 15 61.5
Arthritis - - 9 3.61,2 4 1.60.8 13 5.21.4
Osteohondropathy 6 2.41,0 9 3.61,2 1 0.40.4 16 6.51.6
Tumor 5 2.00,9 6 2.41 3 1.20.7 14 5.61.5
Rachitic deformation 11 4.41.3 7 2.81 - - 18 7.31.7
Joint dysplasia - - 5 20.9 - - 5 2.00.9
Abscess in soft tissues 3 1.20.7 4 1.60,8 - - 7 2.81
Without diagnosis 24 9.71.9 16 6.51.6 12 4.81.4 52 212.6

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1995 -2007 (%)

TABLE 5. PECULIARITIES OF DETECTION AND DIAGNOSTICS

OF OAT IN CHILDREN AND ADOLESCENTS (%)

Method of detection Number of patients (n=248)

abs %
Phthisiatric examination 67 27.02.8
Roentgenogramme, MRI, CT of 172 69.32.9*
skeleton
Addressing for health care 180 72.52.8*
Surgical biopsy 43 17.32.4
During treatment of process in lung 42 16.92.3
Note: * reliable difference with other indicators, <0.05

FIGURE 1. PERCENTAGE OF EXTRAPULMONARY TUBERCULOSIS

AMONG NEWLY DETECTED TUBERCULOSIS FORMS IN
CHILDREN AND ADOLESCENTS DURING

91 9 2007
93 7 2005
91.2 8,8 2003
90.4 9,6 2001 pulm.TB

86.2 14,8 1999 extrapulm.TB

87.3 12,7 1997

89.5 10,5 1995

10 30 50 70 90

Source: Data of statistical analysis, Kazakhstan, 1995-2007.

FIGURE 2. INDICATORS OF OAT INCIDENCE IN CHILDREN AND

ADOLESCENTS IN THE COUNTRY DURING 1995-2007 (per 100.000 of
 children and adolescents population)

2,5 2.2 2.1

2 1.9
1.8
1,5 1.6 1,4 1.4 1.4
1 0.9
1 1 0.9 1
0,5 children

adolescents 0.6
0
1995 1997 1999 2001 2003 2005 2007

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FIGURE 3. GENDER COMPOUND OF CH ILDREN AND ADOLESCENTS

NEWLY DETECTED WITH OAT OVER 1995-200 8 (PER 100.000 OF
CHILDREN AND ADOLESCENTS POPULATION )

1
0,9 boys

0,8 girls
0,7
0,6
0,5
0,4
0,3
0,2
0,1
0
1995 1997 1999 2001 2003 2005 2007 2008

FIGURE 4. DISTRIBUTION OF PATIENTS BY CLINICAL OAT

FORMS AMONG CHILDREN OVER 1995-2007 (ABS)

35 oth. forms
30 osteitis
25 arthritis
20 spondylitis

15

10

0
1995 1997 1999 2001 2003 2005 2007

Source: Clinical repots from oblasts of Kazakhstan, 1995-2007.

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