Gettysburg Medical News
 The Clinical View
 by P.E. Hoffsten, MD
 14 December 2005

TUBERCULOSIS:  FORGOTTEN BUT NOT GONE

            There was a time when tuberculosis was the leading cause of death in the United States.  Unlike the pneumococcus which was discussed last week, tuberculosis often has a prolonged course in adults with months or even years before a mortal outcome occurs.  In the United States and South Dakota particularly, tuberculosis is a relatively unusual condition.  This past month, it reared its ugly head in a very unexpected way.

            The patient was a middle aged diabetic who was treated with insulin.  She had been diabetic for many years and was struggling with the complications including the numb feet and the visual difficulties that often come with insulin dependent diabetes.  Her weight had been dropping over the past year because of difficulty with diabetic nerve damage to her stomach which emptied very slowly.  Because her stomach emptied so slowly, she always felt full and didn’t feel like eating.

            She had an accelerated weight loss in the several months prior to her coming to the clinic with a new turn of events.  On this occasion, she was short of breath with any exertion.  A chest film was taken and showed her heart to be enlarged; but the shadow of her heart was unusual suggesting a condition called pericarditis.  This is an inflammation of the lining around the heart.  To diagnose pericarditis for sure, a test called an echocardiogram is needed.  This is a special kind of test where sound waves from a microphone are bounced off the chest and we can actually take a sound wave picture of the heart.  This allows clear demonstration of fluid on the outside of the heart and is diagnostic of the condition called pericarditis.  When this was found, she was transferred to Rapid City Regional Hospital for further evaluation.  The doctors there initially could find no reason for her pericarditis and surgery was done to alleviate the pressure of the fluid on the outside of her heart.  When this surgery was done, a piece of the tissue was sent to the laboratory where it was found to be infected with tuberculosis.  This would be fatal if not treated with antibiotics.  Fortunately, the condition can be effectively treated and she will recover.  But this was a most unexpected diagnosis.  In my 40 years of medical experience, this is only the second case I have ever seen and many physicians will never see even one in their entire career.  How did this happen and what do the people of central South Dakota need to know about tuberculosis?

            From a historical standpoint, tuberculosis is one of the oldest diseases we are aware of.   Examination of Egyptian mummies demonstrates that the Egyptians had tuberculosis 4000 years ago.  In the early 1900’s, tuberculosis was the leading cause of infectious disease death in the United States.  We learned that the disease is spread by tuberculosis bacteria in cough or sneeze droplets.  Thus, it was a disease of crowded populated cities.  When this was learned, our answer to tuberculosis was sanitariums where individuals with known active tuberculosis could be segregated away from the general population to prevent the spread of the disease.  It wasn’t until 1946 that an antibiotic for tuberculosis was first found and that drug was streptomycin which has to be injected.  Fortunately soon thereafter, different pill forms of anti-tuberculose medications were found.  Today, we have over 10 different medications that will treat the disease effectively.

            It is estimated that approximately 1/3 of all the people in the world are infected with tuberculosis.  In the United States, that number is 15% of the general population who have been infected with tuberculosis at some time.  Most of these U.S.A. citizens infected with tuberculosis are older and were exposed as children in the 1940’s and before.  Fortunately, most people that encounter this bacterium reject it and isolate it in their bodies.  The important thing to know is that the bacteria is not killed.  Rather it is encapsulated and isolated from spreading by the body’s normal defenses.  Thus, most cases of active tuberculosis that need treatment in our society result from a reactivation of these isolated tuberculosis bacteria.

            That is what happened to the lady above.  Sometime, a long time ago, she became exposed to tuberculosis.  She was strong then and was able to reject the tuberculosis bacterium isolating it in her body.  But on the recent occasion of her illness from her diabetes, and her weight loss, her defenses were weakened.  It was at this point, that the tuberculosis bacterium was reactivated.

            Most reactivation tuberculosis will occur in the lungs and the person will develop a cough, fevers, and nonspecific illness.  Very, very rarely as in this lady the reactivation tuberculosis will involve the heart or the bones or lymph nodes at some area in the body.

            Thus in central South Dakota, tuberculosis is something to look for in our population over age 50 who were exposed to tuberculosis years ago as children.  When they were children, they isolated the disease and probably never even knew they had it.  But now as they develop debilitating conditions such as diabetes, malignancies on chemotherapy, alcoholism, emphysema, or heart failure, the tuberculosis can be reactivated and present a very difficult mystery for healthcare providers and for the patient.  If the lady above had reactivated tuberculosis in her lungs, she would have to be isolated until treatment had cleared her sputum of tuberculosis organisms.  Fortunately, the infection is on the outside of her heart.  Because the infection is not in her lungs she is really not contagious.   She simply needs to take her medications.  The one place to expect tuberculosis in the younger population is those with HIV infection.

            In today’s world, medications to treat tuberculosis are remarkably effective.  Usually two or three antibiotics are used for two months and then a prolonged one year program to completely cure the disease.

            Tuberculosis is forgotten by the general public and by many healthcare providers because it is rarely seen, but it is not gone.  We teach medical students that rare diseases account for about 10% of all the medical illnesses they will see.  Most of the time when a person comes to the clinic with a fever and cough and just not feeling good, the problem will be a cold, or flu, or a touch of bronchitis but one time in ten it will be something rare like tuberculosis or babesiosis or eosinophilic pneumonia or heaven only knows what.  Rare diseases are often forgotten but they haven’t gone away.