THE CORRELATION BETWEEN SEX, AGE, NUTRITIONAL STATUS AND DIABETES MELLITUS WITH CLINICAL SYMPTOMS MDR PULMONARY TB AT RSUD DR SOETOMO

Abstract. Multi-drug resistance is a condition where drugs rifampicin and isoniazid is not effective in killing bacteria Mycobacterium tuberculosis. Some of the causes of resistance to OAT are the use of a single drug in the treatment of tuberculosis, the use of drugs is inadequate and the irregular drug administration. In RSUD Dr. Soetomo, 25% of MDR Pulmonary TB patients do not want to be treated because symptoms are mild, no pain and feel the treatment is not comparable with the symptoms. This research is to determine the correlation between sex, age, nutritional status and diabetes mellitus with the clinical description of MDR pulmonary TB patients in RSUD Dr. Soetomo. Hence, it is expected  people can make the earliest possible prevention against this disease. In addition, clinicians are more aware of the symptoms of MDR Pulmonary TB. Method in this research is  descriptive observational study research. There were  103 patients taken as the sample of the study. Research variables consist of sex, age, nutritional status, and diabetes mellitus. The obtained data were analyzed by administering Chi- square analysis. The results of this study showed that each  variable tested in this study (sex, age, nutritional status and diabetes mellitus) associated with the symptoms of MDR Pulmonary TB  has  p 0.05 which means no significant relationship. There are no relation between sex, age, nutrition status and comorbidities with symptom of MDR pulmonary TB.  Keywords: multidrug resistance, sex, age, nutritional status, diabetes mellitus Multi-drug resistance adalah suatu kondisi dimana obat rifampisin dan isoniazid tidak efektif dalam membunuh bakteri Mycobacterium tuberculosis. Beberapa penyebab resistensi terhadap OAT adalah penggunaan obat tunggal dalam pengobatan tuberkulosis, penggunaan obat tidak memadai dan pemberian obat tidak teratur. Di RSUD Dr. Soetomo, 25% pasien TB paru MDR tidak mau diobati karena gejalanya ringan, tidak terasa sakit dan rasakan pengobatannya tidak sebanding dengan gejalanya. Penelitian ini bertujuan untuk mengetahui hubungan antara jenis kelamin, umur, status gizi dan diabetes mellitus dengan gambaran klinis pasien TB paru MDR di RSUD Dr. Soetomo. Sehingga diharapkan masyarakat bisa melakukan pencegahan paling dini terhadap penyakit ini. Selain itu, dokter lebih sadar akan gejala TB paru MDR. Metode yang digunakan dalam penelitian ini adalah penelitian observasional deskriptif. Terdapat 103 pasien yang diambil sebagai sampel penelitian. Variabel penelitian terdiri dari jenis kelamin, umur, status gizi, dan diabetes mellitus. Data yang diperoleh dianalisis dengan analisis Chi-square. Hasil penelitian ini menunjukkan bahwa setiap variabel yang diuji (jenis kelamin, usia, status gizi dan diabetes mellitus) yang dihubungkan dengan gejala TB paru MDR memiliki p 0,05 yang berarti tidak ada hubungan yang signifikan. Kesimpulannya, tidak ada hubungan antara jenis kelamin, usia, status gizi dan komorbiditas dengan gejala TB paru MDR.


Introduction
Pulmonary tuberculosis (pulmonary TB) is a disease that attacks the lungs caused by Mycobacterium tuberculosis. The prevalence of pulmonary tuberculosis in Indonesia is the third after India and China, almost 700 thousand cases, the mortality rate is still 27/100 thousand inhabitants. 1 The high rate of pulmonary TB disease is caused by the easy transmission of this disease. Pulmonary TB is transmitted through air contaminated with Mycobacterium tuberculosis which is released when patients cough. Treatment of pulmonary TB should be noted, in order not to increase the number of infected patients. Multi drug resistance (MDR) is a condition in which rifampicin and isoniazid drugs are not effective in killing Mycobacterium tuberculosis germs. According to WHO, the number of MDR pulmonary TB cases in Indonesia is the eighth of 27 countries. 2 The clinical management of MDR pulmonary tuberculosis is more complicated than drug-sensitive TB because it uses second-line anti-TB drugs, causing tolerance and side-effects. 3 Symptoms of MDR pulmonary TB with symptoms of drugsensitive pulmonary TB are generally the same, such as cough with phlegm for 2-3 weeks or more. Cough may be accompanied by additional symptoms of sputum mixed with blood, shortness of breath, body weakness, decreased appetite, decreased weight, malaise, night sweats without physical activity, fever over one month. 4 Although the symptoms are similar, the treatment of MDR pulmonary TB and pulmonary sensitive drug TB is different. Patients with MDR pulmonary TB should take more drugs than drug-sensitive pulmonary TB for long periods of time. In fact, in Dr. Soetomo, 25% of patients with MDR lung TB will not be treated because of mild symptoms, do not feel pain and feel unequal to treatment. Therefore, it is necessary to do research on the factors that affect the clinical symptom of patients with MDR pulmonary TB in Dr. Soetomo.

Methods
This study used cross-sectional observational research design with the sample size is the total sample, that is all patients of MDR pulmonary tuberculosis treated in RSUD Dr. Soetomo Surabaya for 1 year (January 2015 until December 2015). The samples of the study are MDR pulmonary TB patients who were treated at Dr. Soetomo Surabaya Hospital in period January 1, 2015 -December 31, 2015 whose medical records are found and complete. The research variables were gender, age, nutritional status and diabetes mellitus. The research instrument used is medical record data of patients with MDR pulmonary TB in RSUD Dr. Soetomo for a year starting from January 1, 2015 to December 31, 2015. This research was conducted in TB pulmonary MDR RSUD Dr. Soetomo Surabaya. The data collected in this research is secondary data. Data taken from medical records of patients with MDR pulmonary tuberculosis who have treatment in MDR pulmonary tuberculosis Dr. Soetomo hospital Surabaya in period January 1, 2015 -December 31, 2015. The data were analyzed through Chi-square statistic test, which examined the relationship of sex, age, nutritional status and diabetes mellitus with clinical symptoms of MDR pulmonary TB patients including fever, hemoptysis, night sweats, chest pain, and decreased appetite.

Result
After collecting the data, it was found out that there were 1,293 lung tuberculosis patients who were declared had positive MDR in in East Java. Among them, there were only 142 patients who were willing to be treated in Dr. Soetomo Hospital, Surabaya. However, from the data, it was revealed that there were 103 patients, in which 54 patients were outpatients and 49 patients were unknown developmental treatment. This study used total sampling techniques. It means that all data used in this research. Data collected in this study include sex, age, weight, height, and comorbidities. Based on sex, the most patients are men (58.3%), while female patients (41.7%). The complete distribution can be seen in the table below (Table 1).

Age
The results of the experiments tested with Chi Square showed that each symptom of MDR pulmonary TB with age did not show statistically significant relationship because all p> 0,05.

Comorbidities
The results of the experiments tested with Chi Square showed that each symptom of MDR pulmonary TB with comorbidities did not show statistically significant relationship because all p> 0,05.

Discussion
From the data analysis, it was revealed that the relationship of sex with fever had a p value of 0.395, which means there was no relationship between fever and gender. This is in accordance with research finding conducted by Yondry Kukus et al (2009) who reported that the causes of fever include bacterial disease, brain tumors, and environmental conditions that can end in heat attack. 5 In theory proposed by R.D Myers stated that male sex hormones can increase basal metabolic rate for about 10-15% of normal speed, which causes an increase in heat production. In women, temperature fluctuations are more variable than in men because the ovulation of the hormone progesterone during ovulation increases the body temperature by about 0.3-0.6 ° C above basal temperature. 6 The results of analysis between sex and hemoptysis had p value of 0.825 which shows no statistically significant relationship. Irfa et al (2014) study the ratio of male and female patients who experienced hemoptysis was 1.8: 1. 7 The results of analysis between sex and night sweats had a p value of 0.876 which showed no statistically significant relationship. According Muhtadi (2013), night sweats are more common in men, especially at age <40 years. 8 The results of analysis between sex and chest pain had a p value of 0.825 which showed no statistically significant relationship. Tuberculosis patients with chest pain account for about 4% of all tuberculosis cases in the United States and Brazil, while 20% are in South Africa. In Korea, 2,884 new cases of tuberculosis pleuritis were notified in 2012 that accounted for 7.3% of a total of 39,545 new tuberculosis cases and 34% of all tuberculosis cases. 9 The analysis results between sex and decreased appetite had a p value of 1.0 indicating no statistically significant relationship. This is in line with research conducted by Hendro (2011). 10 Having analyzed the data, it was found out that the relationship between age with fever had a p value of 0.758 which means there was no statistically significant relationship. Research conducted by Zahro (2013) shows that there is no significant relationship between fever and age. 11 In line with previous research conducted by Hendra (2003) that showed no significant relationship between age and fever. 12 The analysis result between age and hemoptysis had p value of 0.321 which showed no statistically significant relationship. According to Mason et al (2010), hemoptysis is common in people with smoking and over 40 years of age. 13 The results of analysis between age and night sweats have a p value of 0.519 indicating no statistically significant relationship. When the condition of TB disease, which is the process of infection or pain of metabolic TB increases, sweat will be increased at night. The analysis result between age and chest pain had p value of 0.743 indicating no statistically significant relationship. In general, chest pain is affected by immune status. 9 The results of analysis between age and decreased appetite had a p value of 0.496 which showed no statistically significant relationship. This is in line with Hendro's (2011) study. 10 In the analysis result, there was no relationship between fever with nutritional status, where p is 0.901. The results of Zahro (2013) showed that there was no significant relationship between nutritional status and the occurrence of fever. 11 From Chi-square analysis results, it was obtained that hemoptysis relationship with nutritional status has a p value of 0.672 which means there was no relationship statistically. The most hemoptysis classification was moderate hemoptysis (34%) with the main etiology of pulmonary tuberculosis (47.6%). From the results of Chi Square analysis, it was revealed that the relationship of night sweat with nutritional status had p value equal to 0,147 which means there was no relation statistically. Based on research conducted by Rumanga, et al (2015), most patients experience symptoms of fever (60%). Fever accompanied by night sweats is a typical symptom in TB patients proven based on the most frequent studies of recurrent type of fever accompanied by night sweats (40%). 13 From Chi Square analysis results, it was obtained that relationship of chest pain with nutritional status has p value of 0.414 which means there was no relationship statistically. Chest pain in pulmonary TB includes mild pleuritic pain that is affected by immune status. 9 From Chi Square analysis results obtained the relationship of decreased appetite with nutritional status had a p value of 0.091 which means there was no relationship statistically.
From Chi Square analysis results, it was obtained that relationship of fever with diabetes mellitus has p value of 0.303 which means there was no relationship statistically. According to Paramitasari (2015), diabetes can affect the body's ability to fight infection. 14 From Chi Square analysis results, it was obtained that hemoptysis relationship with diabetes mellitus had a p value of 1.0 which means there was no relationship statistically. According to Retno Wulandari (2013), lung in DM patients will experience pathological changes, such as alveolar epithelial thickening and pulmonary capillary lamina basalis. 15 From Chi Square analysis result, it was obtained that relationship of night sweat with diabetes mellitus had p value equal to 0,419 which mean there was no relation statistically. Research of Budidarmaja (2013) suggests that if the patient's blood sugar level of 59.4 mg / dl will cause neurologic symptoms of excessive sweating. 16 From Chi Square analysis results obtained relationship of chest pain with diabetes mellitus had p value of 0.714 which means there was no relationship statistically. Chest pain is affected by immune status. 9 From Chi Square analysis results, it was obtained that relationship decrease appetite with diabetes mellitus had p value of 0.223 which means there was no relationship statistically. This is in line with research Renita (2013). 1

Conclusion
In this study there was no relationship between sex, age, status nutrition and diabetes mellitus with clinical features of patients with MDR lung TB.