European Journal of Cardiovascular Medicine

Tuberculosis (TB) is the most common infectious disease in the world which is brought on by the mycobacterium tuberculosis. Despite the development of new diagnostic techniques and therapeutic approaches, it still continues to rank among the major global public health issues.^[1]   It is one of the leading causes of death worldwide and impairs the health of almost 10 million individuals annually. It has surpassed HIV/AIDS as the primary cause of death from a single etiological factor within the past five years. ^[2]The immune system's cell-mediated response explains the disease's pathogenesis. Infection with TB bacilli affects approximately 40% of the Indian population.^[3] The main source of infection is patients with cavitary lesions. Most of these individuals typically have positive sputum smear results. Early diagnosis and therapy are necessary to stop and manage this infection. In addition to the lung tissue, TB also affects the bone marrow. Significant haematological and coagulation abnormalities are linked to TB. Thus, we are able to utilize these haematological and coagulation factors as an indicator of the condition along with likelihood of recoveryand therapy response.^[4]

The purpose of this study was to assess the diagnostic and prognostic significance of early alterations in haematological and coagulation parameters in sputum smear-positive tuberculosis patients and to investigate their variations over time. Haematological markers play a crucial role in therapy planning and treatment follow-up. It might affect how a patient turns out. The haematological and coagulation parameters of the test groups differed significantly from the healthy groups, according to this study. In order to enhance treatment results, patient survivaland quality of life is critical to evaluate and manage infectious diseases such as tuberculosis with regard to haematological and coagulation indicators.^[5] Therefore, these haematological and coagulation parameters are economical and can facilitate prompt attention from doctors and primary health care support teams to diagnose early alterations in tuberculosis patients economically

This study was conducted from January 2023 to July 2023 in the MGM Medical college tertiary care centre pathology department. There are fifty patients with pulmonary tuberculosis (PTB) in this study. The diagnosis was verified by a chest radiograph and the Ziehl-Neelsen staining procedure on sputum. For the purpose of comparing the study's findings fifty healthy controls were added. The basic random approach was used for sampling. Patients were recruited based on their positive status after consulting the chest departmentand blood samples were taken with the patients prior agreement. A case record format was used to document all of the data.

Inclusion criteria

All TB patients (over the age of 18) with positive sputum smears

Exclusion criteria

Patients with extrapulmonary TB and elderly TB with multi-drug resistance (MDR), leukemia, HIV, chronic renal or liver disease and pregnant women are among the groups who were avoided.

Sampling of a total of 50 patients with confirmed tuberculosis was done. Venous blood was drawn in four milliliters with the required aseptic care was followed. Hematological analysis was carried out on two milliliters of blood received in ethylenediamine tetra acetic acid (EDTA) tube blood using the Sysmex XN 1000 6-part haematology analyzer. The remaining two milliliters of blood were utilized to assess fibrinogen and D dimer using the ACL Elite Pro coagulation analyzer's.

Haematological metrics measured were such as hemoglobin (Hb), platelet counts, hematocrit (HCT), total leukocyte count (TLC),mean corpuscular hemoglobin (MCH) and mean corpuscular hemoglobin concentration (MCHC) and coagulation metrics  such as D- dimer and fibrinogen were analysed.

The Statistical Package for the Social Sciences (SPSS) 2.0 program was used to gather and examine the data. The Chi-square test was utilized to examine the correlation between the progression of the illness and hematological markers.

In this investigation, a P value of less than 0.05 was deemed statistically significant

A total of 50 patients with mycobacterium tuberculosis with  recent diagnosis and 50 healthy controls were involved in this study.

The age distribution of tuberculosis cases is displayed in Table 1. The majority of them were in their fourth and fifth decade of life. In sex wise distribution (58%) of the 50 cases were male and  (42%) were female. While the study included an equal number of males and females in the control group

Hematological and coagulation values for sputum-positive patients are displayed in Tables 2a and 2b. Hemoglobin, WBC, platelet countand other indices have all been measured in both the control group and the patients.

We have evaluated anemic parameters in 50 instancesas shown in Table 2a.

Forty seven percent of the cases had mild anemia (Hb: 10–12 g/dl), Forty  percent had moderate anemia (Hb: 8.1–9.9 g/dl)and thirteen percent had severe anemia (Hb < 8 g/dl).

The results of the MCV, MCHand peripheral blood picture were used to determine the morphological type of anemia. The most prevalent kind of anemia is microcytic hypochromic (58%) which is followed by normocytic normochromic anemia (34%).

Despite persistent inflammation35 % of individuals had a normal total leukocyte count (WBC count). Of which leucocytosis was seen in 61%.There was leukopenia in two cases. [Table 2a].

Four individuals (7%) had thrombocytopenia whereas 34 patients (67%) had thrombocytosis. Platelet counts were within normal range in 13 instances (26%) of the total cases.

The majority of thrombocytosis cases had elevated leukocyte counts.Comparing the PCV, MCV, MCH, and MCHC levels to those of healthy normal controls revealed that they were consistently lower. D -dimer levels of 34 cases (69%) were increased and fibrinogen levels 28 cases (57%) were also raised and PT and APTT was also slightly raised in tuberculosis patient

In India, tuberculosis is a major health issue and one of the most significant communicable illnesses worldwide. A productive cough that lasts longer than three weeks, chest pain, and systemic symptoms are all signs of tuberculosis. This includes chills, nocturnal sweats, fever that rises in the evening, pallor, appetite loss, and exhaustion. A chest X-ray and a culture of the sputum or blood are the first steps in the diagnosing process for tuberculosis. Other techniques include skin testing, polymerase chain reaction (PCR) testing, in vitro blood testing, and Interferon Gamma Release Assays (IGRAs). On the other hand, a quick and affordable diagnostic test would be helpful in poor nations. In a situation like this, evaluating hematological parameters is one such economical method.

According to our analysis, 30 cases (60%) are between the ages of 20 and 50. This result showed correlations with research conducted by Rajesh H et al ^[6] Yasin A et al ^[7] and Rohini K et al ^[8]The extreme age group (over 60 years old) had the lowest reported prevalence. Men have been reported to have 63% of tuberculosis cases whereas women had 37% of cases. The results showed strong correlations with those of Thatoi PK et al ^[9] and Banerjee M et al ^[10]

This finding contrasts with a research by Yasin A et al^[7]wherein more instances were reported in women than in men.

Anemia is one of the risk factors for mortality and the most prevalent consequence seen in hematological parameters in patients with tuberculosis. ^[11]

Reduced erythropoietin production, bone marrow depression, and altered iron metabolism are the results of increased release of cytokines such as tumor necrosis factor-α (TNF-α), interferon γ (IFN-γ), and interleukin-6 (IL-6).  ^[12] Additionally, TNF-α and IL-1 promote ferritin production and iron absorption.

In this study, hemoglobin level was used to determine the severity of anemia. Only 13% of the patients had severe anemia, compared to 47% of cases with mild anemia and 40% of cases with moderate anemia.  58 % of the cases exhibiting a microcytic hypochromic pattern and 34% displaying normocytic normochromic anemia. All patients who tested positive for tuberculosis had low levels of PCV, MCV, MCH, and MCH Caside from these. These results are consistent with those of earlier investigations conducted by Yasin et al. ^[7] and Bashir et al. ^[13]

A fundamental characteristic of TB is leukocytosis. According to our analysis, 61% of the cases had leukocytosis,

35 % had a normal leukocyte countand 4% had leukopenia. These results are linked to the conventional conclusion that as part of the body's defense, the WBC count and macrophage count rise in tuberculosis patients during infection process.

Sixty Seven percent of the cases in this investigation had throm bocytos is which was consistent with the results of Yasin et al. [7] and Banerjee M. [10]. Numerous cytokines, including IL-6which are implicated in the formation of granulomas, stimulate the synthesis of platelets and may be the cause of thrombocytosis. Like other immune system cells, active platelet formation is also reflected in many platelet morphological characteristics, such as high platelet distribution width (PDW) and mean platelet volume (MPV) values in TB patients.

WBCs rise during an infection as a result of an increase of polymorphonuclear leukocytes and macrophages, which are part of the body's immune defense system to fight the bacterial population that is invading.^[14]

Research conducted by Oliva et al  showed that while anti-inflammatory activity rises and the platelet count returns to normal with disease progression, platelet count is elevated during the early stages of the illness when there is substantial proinflammatory activity that stimulates thrombocytosis. The fact that most of the individuals in this study had high platelet counts suggests that the cases may have been in the early stages of the disease. ^[15]

Platelet aggregation is also triggered by plasma fibrinogen, which is a crucial ligand for glycoprotein IIB/IIIA functionally. A study by Meade et al demonstrates that a significant factor influencing platelet aggregation is the concentration of plasma fibrinogen. An elevated platelet count is linked to aberrant fibrinolytic activitywhich causes hypercoagulability. ^[16]

In 38% of instances, Pawlinski et al. also noted extended PT. ^[17]

It has been demonstrated that pro-coagulant tissue factor (TF) expression is induced in monocytes/macrophages and the endothelium by immune complexes and numerous other factors that are involved in a variety of infectious illnesses in a healthy state.^[18]

In the current study, APTT was elevated in 51% of patients and was statistically significant whereas a study by Abdullah also found that 44% of cases had prolonged APTTwhich is consistent with the findings of the current study. ^[19]

In 42% of instances, Kaushal et al. also demonstrated extended APTT. In approximately 18% of the patients, Kutiyal et al.'s investigation revealed deranged APTT. The level of fibrinogen was either higher or normal.^[20]

Compared to control subjects, TB patients had considerably greater prothrombin and activated partial thromboplastin times. Furthermore, the TB patients' PT and APTT durations exceeded the standard ranges of 10.2 -13.2  and 30–40  seconds, respectively indicating a depletion of the clotting factors measured. According to aSchouten et al, systemic activation of the haemostatic system is a crucial component of the host defense mechanism aimed at eliminating the offending pathogen when a condition of chronic inflammation develops.^[23]

The prolonged PT and APTT signifies an underlying latent disseminated intravascular coagulation (DIC) in tuberculosis patients making these patients more predisposed to thrombohemorrhagic complications. Lowering of the antithrombin III activity and increased thrombin formation may be responsible for this phenomenon.^[20]

The findings showed that pulmonary TB patients had significantly higher D-dimer levels than controls. These findings suggest that D-dimer might be a significant factor in the onset and progression of pulmonary tuberculosis.

FDP is a byproduct of fibrinogen and fibrin degradation and a sign of increased primary and secondary fibrinolysis ^[21]. Few studies have examined the amounts of FDP in pulmonary tuberculosis. FDP levels in the pulmonary TB were revealed to be greater than in healthy donors by Liu et al. ^[22]

After the completion of study we can conclude that there is a pro coagulant activity that is initiated after the tuberculosis infection.

Compared to the control group TB patients had a considerably greater platelet count . The observed increase may be explained by aberrant platelet activation brought on by the ongoing inflammatory condition. Under normal physiological conditions, platelets remain dormant due to the presence of inhibitory substances such as prostaglandin (PGI2) and nitric oxide (NO) in intact endothelium.

However, endothelial dysfunction results in increased production of thromboxane A2 and von Willebrand factor with reduced levels of PGI2, leading to platelet activation and greater responsiveness in a state of chronic inflammatory response such as in tuberculosis.

The rise observed in tuberculosis patients is caused by the release of bioactive peptides from the alpha and dense granules of activated platelets, which include heparin neutralizing factoralso known as platelet factor 4. According to earlier studies this conclusion is supported.

Compared to control subjects, TB patients had considerably greater prothrombin and activated partial thromboplastin times. Furthermore, the TB patients' PT and APTT durations exceeded the standard limits of 10.2 – 13.2 seconds  and 30 – 40 seconds respectively indicating a depletion of the clotting factors evaluated.

However, disseminated intravascular coagulation (DIC)which consumes clotting components, can be the outcome of an overzealous systemic activation of the haemostatic system. This suggests that both the intrinsic and extrinsic blood coagulation pathways are impacted which explains the extended PT and APTT seen in TB patients.

These TB patients may be more vulnerable to bleeding issues in the case of an injury due to their blood's incapacity to clot. Patients with tuberculosis had a shorter thrombin clotting time than the control group.

This is most likely because the thrombin has been depleted as a result of the TB infection and inflammation's increased stimulation of coagulation.

By binding to thrombomodulin, thrombin inhibits clotting in inflammatory conditions by activating protein C which is a natural anticoagulant that divides factors V and VIII in contrast to thrombin's procoagulant effects. Further explaining the extended PT and APTT seen in tuberculosis patients is the lack of procoagulant capabilities by thrombin. The fibrinogen concentration of tuberculosis patients was found to be considerably higher (p<0.05) compared to the control values. This finding is consistent with reports of hyperfibrinogenaemia, or an increase in fibrinogen levels above the reference value, in tuberculosis patients

There are a number of reasons for the reported rise in fibrinogen levels. First, Mycobacteria and the host's monocyte-macrophage system interact to produce a huge amount of pro-inflammatory cytokines. These cytokines then trigger hepatic acute-phase processes that alter the amounts of coagulation proteinsincluding fibrinogen. It is true that fibrinogen plays a crucial role in controlling the immune system's reaction and inflammation during infection. It functions by causing more fibrin clots to develop, which traps the pathogen.

The small sample size, however, may not be adequate to demonstrate a statistically significant correlation between the various coagulation and hematological markers and tuberculosis which limits the study.

Therefore, in order to raise general awareness among treating physicians, help incorporate the DOTS by RNTPC, and lower disease-related morbidity and death, this study can serve as the foundation for bigger longitudinal investigations in various government and corporate hospitals.