Abstract
A hypothesis for the pathogenesis of pulmonary TB is presented based on the biomechanics of pleural stress in the context of the lung as a pressure vessel. This hypothesis modelled pleural stress as a marker of pleural tissue destruction and subsequent repair. It identified five predictors of TB reactivation, namely adolescent and young adult age, male gender, apical location, low antero-posterior chest diameter or low thoracic-index rib-cage shape and the presence of pre-existing apical blebs.
Highlights
Tuberculosis [TB] still remains a major global health threat especially in middle and low-income countries where it is more prevalent [1] and where multi-drug resistant TB is a serious public health issue [2,3].TB and the apex of the lungTB has long been recognized as having a predilection to the apex of mainly the upper lobe and to that of the lower lobe [4]
This paper proposes the biomechanical pleural stress or pressure vessel hypothesis, presenting supportive evidence and predictions, and builds on these to suggest innovative applications to TB screening
The Pleural Stress model can identify the following five groups as predictors of increased risk of TB reactivation: Apex, low thoracic index/low Body Mass Index (BMI), young age, males and presence of apical blebs
Summary
Tuberculosis [TB] still remains a major global health threat especially in middle and low-income countries where it is more prevalent [1] and where multi-drug resistant TB is a serious public health issue [2,3]. FEA simulation data showed the presence of three areas of high stress activity in the apical region present near the apex and within two grooves on either side of the apex caused by the first rib furrows, with maximal stress fortyfold-higher than basal low stress areas, see Figure 2 This mathematical model cannot be directly validated experimentally since it is not practical to measure pleural stress in-vivo, this model has been used successfully to explain the pathogenesis of primary spontaneous pneumothorax (PSP) and predict those at high risk of developing PSP [31]. Seven cohort studies on TB have linked BMI and incidence of TB in several countries across a spectrum of high, intermediate and low TB incidences [2023,36-38]
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