Tuberculosis (TB), caused by Mycobacterium tuberculosis, is a chronic infectious disease that primarily affects the lungs but can also involve other organs. It remains a major global health challenge, especially in developing countries. In 2023, approximately 10.8 million new TB cases were reported globally, with India accounting for nearly 27% (2.28 million cases) of the burden, making it the highest contributor worldwide. Despite the launch of the National Tuberculosis Elimination Program (NTEP) in 2020, TB continues to pose a serious threat in India due to persistent prevalence and rising comorbidities such as HIV and diabetes¹. TB spreads through inhalation of aerosolized bacilli and often remains latent. Active disease develops in individuals with weakened immune responses. Age significantly influences TB epidemiology and outcomes. Though TB is most prevalent in the 15–30 age group in India, recent data shows a growing burden among the elderly.2 Factors such as immunosenescence, malnutrition, and comorbidities like diabetes and chronic respiratory conditions increase susceptibility in older adults. With India's elderly population (currently 7.7%) expected to reach 12.6% by 2026, addressing TB in this demographic is increasingly urgent.3 Clinical presentations differ by age. Younger individuals usually exhibit classic symptoms like chronic cough, fever, hemoptysis, and night sweats. Conversely, elderly patients often show atypical signs, such as dyspnea, weight loss, and general malaise, leading to diagnostic delays and poor treatment outcomes. Radiologically, younger patients tend to show cavitary lesions and upper lobe involvement, while elderly patients more frequently present with non-cavitary infiltrates and lower lobe involvement, complicating diagnosis.4 Bacteriologically, literature remains sparse regarding comparisons between geriatric and non-geriatric profiles. However, elderly patients often have higher rates of smear-negative pulmonary TB (SNPT), comprising 30–60% of all pulmonary TB cases and associated with mortality rates up to 25%⁸. Atypical symptoms and negative smear results further hinder diagnosis.5 Despite over two decades of DOTS implementation, few studies have evaluated its long-term impact across age groups. Comparative research on clinico-radiological and bacteriological differences between age groups remains limited in India, underscoring the need for targeted diagnostic and management strategies to improve outcomes for all TB patients.6

Study Design: This hospital-based cross-sectional and observational study was conducted over 18 months in the Department of Respiratory Medicine at Mahatma Gandhi Medical College & Hospital, Jaipur. Data were collected using a structured proforma from patients attending OPD or admitted. Participants were divided into non-geriatric (18–64 years) and geriatric (65+ years) groups. After obtaining informed consent, detailed clinical histories, examinations, and relevant investigations were conducted as per the study protocol. Inclusion Criteria: Patients included in the study were those clinically diagnosed with pulmonary tuberculosis and aged 18 years or older, categorized into Non-Geriatric (18–64 years) and Geriatric (≥65 years) groups. Additionally, all patients who presented with pulmonary tuberculosis to the Department of Respiratory Medicine at Mahatma Gandhi Medical College & Hospital, Jaipur, were considered eligible for inclusion in the study based on the outlined clinical and age-specific criteria. Exclusion Criteria: Patients younger than 18 years of age were excluded from the study. Age Classification: The age distribution of patients in the study was categorized according to the National Institutes of Health (NIH) guidelines. Individuals aged between 18 and 64 years were classified as the Non-Geriatric Group, while those aged 65 years and above were categorized as the Geriatric Group. This classification facilitated age-based comparison and analysis of clinical patterns and outcomes among patients with pulmonary tuberculosis.

Table No- 1 Distribution Of Patients According To CBNAAT. CBNAAT Geriatric Non-geriatric P-Value No. of Patients Percentage No. of Patients Percentage Mtb detectedRif Sensitive 65 65 60 60 0.71 Mtb detectedRif resistant 0 0 2 2 Not detected 35 35 38 38 Total 100 100 100 100 Among geriatric patients, 89% were aged 65–75 years, with a mean age of 69.68 years; 67% were male. In the non-geriatric group (mean age 46.38 years), most were aged 46–60 years, with 54% males. Mycobacterium tuberculosis was detected in 65% of geriatric and 60% of non-geriatric patients, with rifampicin resistance seen only in 2% of non-geriatric cases. Differences in gender and Mtb detection were not statistically significant. Table No- 2 Distribution of patients according to Chest X-ray Findings. Chest X-ray Findings Geriatric Non-geriatric P-Value No. of Patients Percentage No. of Patients Percentage Radiological Extent U/l Right 35 35 27 27 0.34 U/l Left 18 18 16 16 B/l 47 47 57 57 Total 100 100 100 100 Radiological involvement was bilateral in 47% of geriatric and 57% of non-geriatric patients. Right-sided unilateral findings were noted in 35% of geriatric and 27% of non-geriatric patients, while left-sided involvement occurred in 18% and 16%, respectively. The distribution patterns showed no statistically significant difference between the two groups (p = 0.34). Table No- 3 Distribution of patients according to Chest X-ray Findings. Chest X-ray Findings Geriatric Non-geriatric P-Value No. of Patients Percentage No. of Patients Percentage Zone All Zone 33 33 37 37 0.82 Upper zone 23 23 21 21 Middle zone 8 8 9 9 Lower Zone 33 33 33 33 Upper and Middle zone 2 2 0 0 Upper and Lower zone 1 1 0 0 Total 100 100 100 100 In the geriatric group, 33% had all-zone involvement, 33% lower zone, 23% upper zone, 8% middle zone, and a small percentage had combined upper-lower (1%) or upper-middle (2%) zone involvement. In the non-geriatric group, 37% had all-zone involvement, 33% lower, 21% upper, and 9% middle zone involvement, with no combined zone cases. The zonal distribution between the two groups was not statistically significant (p = 0.82). Table No- 4 Distribution of patients according to Bronchoscopy. Bronchoscopy Geriatric Non-geriatric P-Value No. of Patients Percentage No. of Patients Percentage BAL AFB + 11 31.42 14 36.84 0.6 BAL CBNAAT + 35 100 38 100 0.9 Total BAL taken Patients 35 100 38 100 0.9 Bronchoalveolar lavage (BAL), in the geriatric group, 31.42% (11 out of 35) tested positive for BAL AFB, compared to 36.84% (14 out of 38) in the non-geriatric group, with no statistically significant difference (p = 0.6). BAL CBNAAT was positive in 100% (35 out of 35) of geriatric patients and 100% (38 out of 38) of non-geriatric patients, also showing no significant difference (p = 0.9). The total number of BAL procedures was comparable between the groups (p = 0.9).

Pulmonary tuberculosis remains a major health issue, with differing presentations in geriatric and non-geriatric patients due to age-related immunity and comorbidities. Elderly patients often show atypical symptoms and non-classical radiological findings, leading to diagnostic delays, while younger patients typically present with classic respiratory symptoms and upper lobe cavitations. This study compares the clinico-radiological and bacteriological profiles across age groups.7 Shortness of breath was reported in 61% of geriatric and 57% of non-geriatric patients (p = 0.56), while fever occurred in 66% and 73%, respectively (p = 0.28). Cough was the most common symptom, seen in 90% of elderly and 96% of younger patients (p = 0.09), with expectoration reported by 78% and 80% (p = 0.72). Haemoptysis (22% vs. 11%, p = 0.03) and chest pain (35% vs. 17%, p = 0.003) were significantly higher in the elderly, whereas weight loss and appetite loss were similar in both groups (~55% vs. 59%, p = 0.56). Agarwal A et al8 compared 65 tuberculosis cases with 55 controls and found that cough (98.4% vs 74.2%) and dyspnea (93.8% vs 60.5%) were significantly more prevalent among the case group, with p-values less than 0.001. In contrast, symptoms such as fever, chest pain, haemoptysis, and anorexia did not show any significant difference between the two groups. Similarly, Rawat J et al9 analyzed the clinico-radiological profiles of adult and elderly TB patients and reported that adults exhibited markedly higher frequencies of haemoptysis (29.5% vs 6%), fever (95.4% vs 76%), and night sweats (54.5% vs 18.0%), suggesting more intense symptomatology in the younger age group. In the current study, bilateral (B/l) chest X-ray involvement was observed in 47% of geriatric patients and 57% of the non-geriatric group, with right-sided unilateral (U/l) lesions found in 35% of geriatric and 27% of non-geriatric patients, while left-sided involvement occurred in 18% and 16%, respectively. These differences were not statistically significant (P = 0.34). Similarly, Bainara M K et al10 reported bilateral lesions in 65% of new and 74% of previously treated cases, with unilateral lesions at 35% and 26%, respectively, also without significant difference (p = 0.30). Likewise, Joshi J L et al11 noted that upper lobe infiltrations predominated across all age groups, especially in the 20–34 and 50–64 age ranges, while middle lobe involvement varied between 2.8% and 9.6%, and bilateral infiltrates were frequently seen in the 20–49 age group. In contrast, lower lobe involvement was rare. In the geriatric group, 33% had all lung zones involved, 33% lower zone, 23% upper zone, 8% middle zone, and a few showed combined upper-lower (1%) or upper-middle (2%) involvement. In the non-geriatric group, 37% had all zones affected, 33% lower zone, 21% upper zone, and 9% middle zone, with no combined zone involvement. The zonal distribution did not differ significantly between groups (P = 0.82). In a similar study, Qazi M A et al12 examined 150 chest radiographs and observed that right lung involvement was most common (84 cases), followed by the left lung (39 cases), with bilateral lesions in 27 films. Likewise, non-homogeneous opacities appeared most frequently (75 films), while cavities were identified in 31 cases. Homogeneous shadows and multiple opacities were each noted in 22 films, reflecting diverse radiological patterns with a clear predominance of right-sided and non-homogeneous findings. Likewise, Jagdish Rawat et al9 highlighted that elderly patient had a greater prevalence of lower zone involvement (24.0% vs. 7.9%) and more far-advanced lesions (32.0% vs. 14.7%), suggesting more extensive and atypical presentations in older individuals. In this study, Bronchoalveolar lavage (BAL) testing for AFB was positive in 31.42% (11 of 35) of patients in the geriatric group and 36.84% (14 of 38) in the non-geriatric group, with no statistically significant difference between the two (p = 0.6). Similarly, BAL CBNAAT yielded positive results in 100% of both geriatric (35 of 35) and non-geriatric patients (38 of 38), also showing no significant difference (p = 0.9).Likewise, Hussein M T et al13 reported greater use of bronchoscopic diagnostics in elderly patients, with overall bronchoscopy performed in 16.2% of elderly versus 3.9% of younger patients. Bronchoalveolar lavage smear/culture and bronchoscopic biopsy were also more frequently employed in the elderly (8.9% and 7.3%, respectively) compared to the young (2.3% and 1.6%), indicating a higher dependence on invasive diagnostic techniques in the older population.

This study reveals that elderly patients with pulmonary tuberculosis often present with non-specific symptoms and atypical radiographic findings, making diagnosis difficult and delaying treatment. These delays contribute to higher morbidity and mortality in older adults, despite TB being preventable and treatable. The study emphasizes the need for heightened clinical suspicion in elderly patients with vague respiratory symptoms. It also highlights the importance of addressing modifiable risk factors and recommends targeted public health measures. Additionally, an integrated screening approach, including systematic HIV testing and screening for other comorbidities, is advocated to improve outcomes.

1. Global tuberculosis report. Geneva: World Health Organization; 2023 2. Ministry of Health and Family Welfare. Central TB division. India TB Report. 2019. 3. Ministry of Statistics and Programme Implementation. Elderly in India. 2016. 4. Mohan V, Devi S. Initial higher sputum graded patients treated under category-II RNTCP (DOTS) with Low weight gain tend to have more relapse rate. Int J Sci Res. 2017;6(8):1896-903. 5. Campos LC, Rocha MV, Willers DM, Silva DR. Characteristics of patients with smear-negative pulmonary tuberculosis (TB) in a region with high TB and HIV prevalence. PloS one. 2016 25;11(1):e0147933. 6. Wang H, Yu M, Ochani M, Amella CA, Tanovic M, Susarla S, et al. Nicotinic acetylcholine receptor alpha7 subunit is an essential regulator of inflammation. Nature 2003;421:384 8 7. Rajaram M, Malik A, Mohpatra M M, Vijayageetha M et al. Comparison of clinical, radiological and laboratory parameters between elderly and young patient with newly diagnosed smear positive pulmonary tuberculosis: a hospital-based cross sectional study. Cureus 12(5): e8319. 8. Agarwal A, Agrawal VK. Impact of tobacco smoke on tuberculosis: A case control study. NJIRM 2011;2:38 42. 9. Rawat J, Sindhwani G, Juyal R. Clinico-radiological profile of new smear positive pulmonary tuberculosis cases among young adult and elderly people in a tertiary care hospital at Deheradun (Uttarakhand). Ind J Tuber. 2008;55(2):84-90. 10. Bainara M K, Damor N, Arya M K. Comparative study of clinico-radiological profile of pulmonary tuberculosis in new and previously treated patients of geriatric age. International journal of scientific research 2018;7(6). 11. Joshi JL, Devi S, Mohan V, Kaur RP, Kaur R: Clinico-radiological variability of pulmonary tuberculosis in young patients as compared to elder patients prior to RNTCP and after 18 years RNTCP. Int J Res Med Sci. 2018; 6:2116 12. Qazi M A, Sharif N, Warraich M M, Imran A, Haque I U, Attique M U H, Gardezi MA, Chaudhary G M. Radiological Pattern of Pulmonary Tuberculosis in Diabetes Mellitus. ANNALS 2009; 15(2). 13. Hussein MT, Yousef LM, Abusedera MA. Pattern of pulmonary tuberculosis in elderly patients in Sohag Governorate: Hospital based study. Egyptian Journal of Chest Diseases and Tuberculosis (2013); 62:269–274.