[Prognosis of acute tuberculous respiratory distress syndrome. 4 cases]

We examined the characteristics of 4 cases of adult respiratory distress syndrome in patients with tuberculosis in an attempt to improve prognosis.

Four new cases of adult respiratory distress syndrome were described together with a review of the cases reported in the literature. Inclusion criteria were the presence of the syndrome as defined according to the American-European consensus conference and the criteria described by Murray et al. and identification of the mycobacteria causing tuberculosis.

A total of 52 cases were included in the study. The sex ratio was 0.71 and mean age 46 +/- 15 years. Eight patients had a past history of pulmonary tuberculosis. Alcoholism was the primary immunodepression factor observed (35%) followed by human immunodeficiency virus infection (13%). For 74% of the patients, the disease course lasted 7 days. The initial chest X-ray was suggestive of tuberculosis in 11. Intradermoreaction to tuberculin was positive in 2 out of 17 patients. Direct examination of non-invasive respiratory samples was positive in 44% for mycobacteria. Disseminated tuberculosis was seen in 64%. Anti-tuberculosis antibiotherapy was started on the first day of intensive care in 68% of the patients; rapid treatment was associated with better prognosis: 1.5 +/- 1.2 days versus 3 +/- 2.7 in fatal cases (p = 0.02). Adjuvant corticosteroid therapy was used in 46% of the cases and was apparently associated with unfavourable outcome: 74% mortality versus 58% without corticosteroids. Ventilatory assistance was required in 88% and associated with poor prognosis (13% survival versus 100% without assistance) (p < 10(-3)). Outcome was fatal in 36 cases (70%) with a mean delay of 9.7 +/- 10.8 days.

The conditions required for improving the prognosis of adult respiratory distress syndrome in tuberculosis patients included suspecting tuberculosis in all cases of acute respiratory failure of unknown origin, particularly in the immunodepressed patient, and to avoid missing this diagnosis in case of a non-suggestive chest X-ray and a negative though exhaustive microbiology search. Adjuvant corticotherapy is uneffective and may be dangerous.