Introduction : Non-healing wound causes significant morbidity and mortality of patients. One of the rare causes behind nonhealing wound infection is M. tuberculosis which often remains undiagnosed.
Aim : The aim of this study was to determine the tuberculosis as one of the causes of non-healing wound.
Methods Wounds that did not heal even after secondary suturing and tissue biopsies were sent for histopathological examination. The cases diagnosed with tuberculosis received anti-tubercular treatment. Follow-up was done after 7 and 14 days of treatment, and response was seen in terms of reduction in inflammation and discharge.
Results: Of the 36 patients, five patients had tubercular infection out of which one patient revealed tubercular granuloma, two revealed epitheloid cells, Langhans cells, whereas two revealed non-specific chronic inflammation in histopathology.
Conclusions: A high degree of suspicion and tissue biopsy is required in case of delayed or non-healing wounds to diagnose tuberculosis as a cause. Even if typical tubercular granuloma is not visible in histopathology, the presence of epitheloid cells, giant cells, Langhans cells or predominant lymphocytic infiltrate equally suggests tubercular tissue infection.
Keywords Non-healing wound · Tubercular granuloma · Epitheloid cells · Langhans cells and wound tuberculosis
Non-healing wounds remain a major cause of morbidity in post-operative patients mostly owing to anaemia, obesity and immune compromised state. Lack of suspicion and difficulty in diagnosis of wound tuberculosis adds in increasing the morbidity by further delaying the wound healing. This occurs mostly due to reactivation of latent tuberculosis that is defined as a state of persistent immune response to mycobacterium tuberculosis antigens, which is harbouring as a primary focus somewhere else in the body, with no evidence of clinically manifest active TB [1].Tuberculosis is an ancient disease and has been described in the earliest literature: Rig Veda and Atharva Veda as YAKSHMA, but unfortunately it is still not a disease of the past. As per the Global TB Report 2017, the estimated incidence of TB in INDIA was approximately 28,00,000 accounting for about a quarter of the world’s TB cases [2]. Latent M. tuberculosis infections present one of the major obstacles in gaining complete remission of tuberculosis. The aim of this study was to determine the tuberculosis as one of the causes of non-healing wound.
Materials and Methods
Type of Study: Prospective observational study
Place of Study: Department of Obstetrics and Gynaecology,
M.L.N. Medical College, Prayagraj, UP
Duration of Study: 12 months (August 2018–July 2019)
Sampling Method: Incidental sampling
Sample Size: 36 patients, divided in two groups
depending upon evidence of wound tuberculosis in wound
biopsies.
Case group-: Cases with evidence of wound tuberculosis
in tissue histopathology; n = 5 (13.88%).
Control group: Cases without evidence of tubercular
infection in tissue histopathology; n = 31 (86.11%).
Inclusion Criteria: Non-healing surgical site wounds
Exclusion Criteria
Procedure Patients operated for LSCS or abdominal hysterectomies
with non-healed wounds even after secondary
suturing were included in this study. Pus/discharge from
wounds was sent for culture and sensitivity. All related
investigations like CBC and blood sugar estimations were
done. Tissue biopsies from the margins of the wound were
sent for histopathological examination. The presence of
tubercular granuloma and/or epitheloid cells/giant cells/
Langhans cells and/or predominant lymphocyte infiltrates
was taken as positive findings to diagnose wound
tuberculosis.
Assessment Parameter Response to anti-tubercular
treatment in terms of reduction in inflammation and discharge
on day 7 and day 14 and beyond.
Most of the study population belonged to 20–40 years of
age, had low parity and were from rural background and
of lower middle/lower classes. The BMI of most of the
patients was normal to overweight (18.6–29.99). All the
demographic variables in both the groups were comparable
(Table 2). Most of the patients had serosanguinous
discharge, and rest had purulent discharge; however, the
difference was statistically nonsignificant, but the presence
of pain was much less in the case group with statistically
significant difference (P value < .05).
Bacteriological study of wound discharge was more or
less negative (80%) in the case group but positive in the
control group (58%). However, the difference was again statistically
nonsignificant. In both the groups, anaemia was
the most commonly associated co-morbidity (80%; 90.32%)
followed by obesity with no significant difference (Table 3).
The patients had varied presentations, but the ultimate
outcome was little or no sign of improvement with traditional
antibiotics and regular dressing (Table 4). All patients
had no positive contact history with tuberculosis patients.
Histopathologically, typical tubercular granuloma was found
in only one patient (20%); predominant chronic inflammatory
infiltrates, lymphocytes without giant cells or epitheloid
cells were there in two patients (40%); the presence of epitheloid
cells and giant cells was there in two patients (40%)
(Table 5). Healing process was earliest (within 7 days) most
commonly evidenced by reduction of discharge (60%) and
subsidence of inflammation took a little longer (more than
7 days) in most of the patients (60%) (Table 6).
Non-healing post-operative wound significantly increases
the morbidity of the patients putting them under financial,
psychological as well as social stress. It also spoils the reputation
and peace of the treating obstetrician–gynaecologist.
Though the majority of non-healing wound cases were middle-
aged (20-40 years), from rural background and of low
socio-economic status, the nonsignificant difference in case
and control group states that any of the patients presenting
with non-healing wound may have wound tuberculosis even
in the absence of active tuberculosis somewhere else in her
body as has also been shown by Kiazyk et al. [3]
Most of the times, the bacteriological study of the wound
discharges was negative and we considered this negativity
as the result of antibiotics the patients were already having.
This is a proven fact that bacteriological cultures of the body
secretions in patients on antibiotics are usually negative as
shown by Perveen et al. [4]. High positivity rates of wound
tuberculosis in culture negative patients in this study emphasise
on having suspicion of wound tubercular infections in
patients with negative bacteriological culture, that too more
if pain is either nil or mild.
Abdominal wound healing is related to the general condition
of the patient as well as the abdominal obesity as also
described by Pierpont et al. [5]. The presence of anaemia,
obesity and diabetes definitely adversely affects the wound
healing; the nonsignificant difference in the presence of
these co-morbidities in case and control groups shows that
these factors per se do not increase the chance of wound
tuberculosis and hence advocates the suspicion of tubercular
wound infection in all the patients with delayed wound
healing and recommends sending tissue biopsies to confirm
the diagnoses. The same recommendations have also made
by Mazid et al. [6].
Since we excluded the patients who were on anti-tubercular
treatment as well as none of our patients had clinical
symptoms of tuberculosis, the occurrence of wound tuberculosis might be due to reactivation of latent tubercular
focus at primary sites. India being a very high prevalent
country with tuberculosis, more so in Uttar Pradesh (India
TB Report 2019) [7], we all carry a dormant focus in our
bodies that tends to reactivate whenever the immunity
falls. Trauma or surgery additionally raises the chances of
infection causing local vascular derangements and altered
tissue vitality. It has been estimated that 5–10% of latent
infections reactivate and cause active tuberculosis when
patients health gets compromised (WHO) (Figs. 1, 2)
Epitheloid cells and predominant presence of lymphocytes
equally suggests tubercular wound infection in areas of
high prevalence like ours.
Here, we wish to acknowledge that all the patients who
were started with anti-tubercular treatment were reported
to the institutional department of TB/chest in accordance
with government order by Department of Health and Family
Welfare in 2018.
Conflict of interest We certify that we have no affiliation with or involvement
in any organisation or entity with any financial interest
(such as honoraria, educational grants, participation in speakers) or
non-financial interest (such as personal or professional relationship,
affiliation, knowledge) in the subject matter or material discussed.
Informed Consent for Human Studies All procedures followed were in
accordance with ethical standard of responsible committee on human
experimentation (institutional and national) and with Helsinki Declaration
of 1975, as revised in 2008. Informed consent was obtained from
all patients for being included in the study.
