Rishu Pandey was used to living with a cough, which would last for months at times, since childhood.
About two and a half years ago — during the pandemic and while she was studying in a Mumbai college — she had yet another bout of chronic cough. She was treated for allergy, but no test was done.
“I felt better over the months, but the cough did not go away completely,” says Pandey, who is now 23 and pursuing a master’s degree in Ireland. “In January 2022, it turned bad. In May, the cough was accompanied by chest pain.”
Pandey was ultimately diagnosed with pulmonary tuberculosis.
Link between cough and delayed lung TB diagnosis
What Pandey did not know at the time was that hers was just one of the many cases where cough comes in the way of a timely lung TB diagnosis.
“I underwent a chest X-ray at the private hospital I went to with my complaint of cough and chest pain,” says Pandey. “I tested negative for TB in the sputum test. But the skin test done for TB came out positive and I was admitted.”
Multiple medicines, including steroids, were given to her. Result: between just June and July 2022 her weight increased by 5kg. But there with no improvement in her condition.
That’s when Pandey sought treatment from Dr Lancelot Pinto, pulmonologist and epidemiologist, PD Hinduja Hospital, Mumbai. “Only after consulting Dr Pinto did I learn that I was earlier unnecessarily put on steroids and multiple medication to prevent brain TB,” she says.
Dr Pinto says Pandey was overtreated and put on medications that are not needed for treating the standard tuberculosis she had. After he altered Pandey’s treatment regime, she became TB-free by February 2023.
Causes of delay in TB diagnosis
Ironically, when diagnosed with the condition, Pandey was working with the social media team of ‘Survivors against TB, but was unaware of her own infection.
“Since my childhood, I had undergone chest X-rays multiple times whenever my cough was uncontrollable,” Pandey told Happiest Health from Ireland. “I had a TB scare when I was in Class X, but I hadn’t tested positive.”
In India, people often don’t stick to a doctor consistently and that can create a problem in the diagnosis as well, says Dr Pinto.
“If you have a long-standing cough, you go from one doctor to another, don’t connect the dots,” he says. “So it’s not always that it’s just a misdiagnosis, sometimes it’s also because a person is not following it up with the same doctor.”
Besides, Dr Pinto adds that sputum is not tested enough in TB diagnosis. “When it is tested, the molecular tests that are preferable are not used enough,” he says. He adds that for some reason more weightage is given to X-rays, but they are not done at the right time.
In Pandey’s case, typical TB symptoms — including cough, fever, pain in the chest, formation of lymph nodes — were seen, but there was no weight loss. Still, she was initially treated for allergy.
Dr Pinto says that unfortunately cough syrups are usually tried at first when a person complains of cough — and this can continue for long time.
“And then antibiotics are used, followed by inhalers,” he says. “And then somebody actually realises that something is going wrong and then decides to conduct the tests, such as a sputum test and an X-ray. This has been the pattern in most cases and it is not uncommon.”
Dr Ravindra Mehta, founder director, Vaayu Chest and Sleep Specialists, and head, department of pulmonology, Apollo Hospitals, Bangalore, says that misdiagnosis and delay in TB diagnosis are not uncommon. But there can be more clarity with further investigations, scans and expertise and skills.
“In addition, one must check for symptoms like recurrent fever, loss of weight and appetite,” says Dr Pinto.
He adds that the delay in diagnosis is also because those having typical symptoms of TB do not get themselves tested as soon as they should. A person may initially feel better with antibiotics, but the symptoms may return. “When you do not know the cause of the infection and treat in the dark with antibiotics momentarily, one might not necessarily think that there could be a bigger problem,” says Dr Pinto.
Earlier diagnosis, better treatment
What also leads to misdiagnosis is the spread of viral infections and air pollution, which also lead to cough. “In a densely crowded city like Mumbai, most of the population would be having coughing bouts three-four times in a year for different reasons,” said Dr Pinto. “So, I can understand that a general practitioner may not advise a chest X-ray or a sputum test for everyone coming with symptoms of cough. So, some of the delay in TB diagnosis is unfortunately expected, just because cough is such a common symptom.”
Dr Mehta adds that the earlier the diagnosis, the better is the response to the treatment. “Infectivity to the population can be controlled,” he says. “An undiagnosed infective TB will spread the infection to many, and that’s not in line with our efforts to eradicate TB.”
According to Dr Mehta, non-chest TB can be challenging to diagnose and hence needs a keen index of suspicion for appropriate diagnostic tests. “Referral to a specialist should be done in time so as to make the clinical course better for the infected person,” he says.
Takeaways
Coughing is a symptom seen with multiple health issues, right from a viral bout to allergy to pulmonary TB if it continues for weeks. In most cases, a delay in lung TB diagnosis is noticed due to a lack of timely investigative tests. The tendency to change the treating doctor frequently also comes in the way of diagnosis.
