Tuberculosis: Still a killer

Thirty years ago, I once checked an x ray on one of our patients in New Mexico, noticed her TB scars had changed, so I sent her for a bronchoscopy and indeed they found her tuberculosis had reactivated. The problem was missed by other doctors there, because most younger doctors had never seen a case, but I had: in Africa, but also in medical school where we saw coal miners whose damaged lungs made them vulnerable to the disease.

Thirty years ago, TB essentially was "cured" so many younger docs had never seen a case: but those of us who had trained overseas, and of course those of us who had worked in the IHS had seen cases, since Tuberculosis was a major killer of AmerIndians due to poverty (something to remember the next time you read hysteria about residential school mass graves). 

Ironically, I was not congratulated on my diagnostic ability: the nurses were annoyed because it mean we had to screen all staff and other patients who had been in contact with that patient, and that meant a lot of time and energy on our already overworked staff.

Sigh.

 Nowadays doctors are probably more likely to diagnose TB, because we see more of it:  HIVpostive patients are at risk as are recent migrants and refugees, especially those who didn't get pre immigration screening before entering the USA.

Screening is important to detect silent cases that can lead to clusters of disease. 

Usually if you test positive on a skin test, they check your x ray to see if you have active disease. If the CXR is okay, you are given several months of INH or similar medicine, which theoretically kills the last germ and cuts the rate of the disease being revived when your immune system gets sluggish from old age, diabetes, etc.

Long technical but easily readable article on TB screening here.

For example we started screening our AmerIndian patients and treating our diabetic patients if they had a history of a positive skin test because of the danger of reactivation. Those at risk we treated with a short course of an anti tuberculosis drug.

TB is a two step disease: You get infected and in rare cases, it spreads all over the body and kills you. But usually your body destroys the germ, or walls it off.

When walled off imperfectly, you get classical pulmonary tuberculosis, but most people sucessfully wall off the germ... but a skin test will show you have immune cells so had been infected in the past. But it also means that if your immune system gets sluggish, these germs can reactivate and cause the disease.

In the 1800s TB was a major cause of death: aka the White Plague. 

This is one of a series of lectures at Grescham college about the disease:

So what made me write this long boring essay?

This essay at Crimereadblog (Via TeaAtTrianon) which notes that Jane Austen died of Addison's disease and decides it was due to autoimmune problems. 

Auto immune disease is trendy today, of course, and since we have sensitive tests for these disease is easy to diagnose even mild cases.

But the article is missing the elephant in the living room: Tuberculosis.

200 years ago, the most common cause of Addison's disease was Tuberculosis.

When Thomas Addison described his patients with adrenal cortex insufficiency in 1855, all cases were due to destruction of the adrenal cortex by Mycobacterium tuberculosis

Addison's disease is when the adrenal gland doesn't put out enough cortisone.

This article describes symptoms of those having this disease.

The most common symptoms of adrenal insufficiency are chronic, or long-lasting, fatigue muscle weakness loss of appetite weight loss abdominal pain

Jane's symptoms are discussed in this medical article::

Jane Austen's letters describe a two-year deterioration into bed-ridden exhaustion, with unusual colouring, bilious attacks and rheumatic pains. In 1964, Zachary Cope postulated tubercular Addison's to explain her symptoms and her relatively pain-free illness. Literary scholars later countered this posthumous diagnosis on grounds that are not well substantiated, while medical authors supported his conclusion.

 Important symptoms reported by contemporary Addison's patients-mental confusion, generalised pain and suffering, weight loss and anorexia-are absent from Jane Austen's letters. Thus, by listening to the patient's perspective, we can conclude it is unlikely that Addison's disease caused Jane Austen's demise.

maybe, or maybe not. She might have had mild Addison's disease, and didn't go into crisis until another disease stressed her body, which is what happened to JFK (discussed below).

or maybe she had caught TB from food or milk? 

(however) Disseminated bovine tuberculosis would offer a coherent explanation for her symptoms, so that Cope's original suggestion of infective tuberculosis as the cause of her illness may have been correct.

 In other words, without an autopsy, it is unlikely to solve the mystery of Jane's early death.

this article is a case study showing that even today it is hard to diagnose Adrenal TB. 

And I answer: well, yes. 

Which is why we often just treat the patient who is suspected of having TB with medicines and see if they get better while waiting for the tests to come back. (in the case study at the link, it took two months to diagnose the poor patient, even though the doctors knew he had TB as a child).

the most famous modern person with TB is Orwell who died, alas, about the time Streptomycin became available to stop the disease.

Over 1.5 million people a year die of TB: 

So yes, TB is a treatable disease, even with the problem of drug resistance. The problem is that you have to take medicine for a long time and get check ups during that time, and alas that takes time, money, and trained personnel.

the covid epidemic made it worse for the same reason that we are seeing increased deaths from heart attacks/ high blood pressure/diabetes/ preventable diseases in kids: screening is not being done, cases are not diagnosed because people are not being screened and/or not presenting themselves to clinics for XRay when they develop a chronic cough, and public health resources are focusing on covid.

Sigh.

TRIVIA QUESTION: WHO IS THE MOST FAMOUS PERSON WITH ADDISON'S DISEASE?

The most famous modern person with Addison's disease was JFK: and his was mild and only caused trouble when his adrenal glands failed to produce more cortisone under the stress of his back surgery. Luckily docs diagnosed it and gave him a new miracle drug called cortisone and saved his life, and wrote up his case in the medical literature to alert other docs about the problem of mild Addison's disease in times of stress. But when the press found out about it, the fact he took small replacement doses of cortisone spawned a thousand conspiracy theories.

as for the source of Jane's possible Addisone disease: staying in crowded boarding homes at spas or catching it from her clergyman father or Naval officer brothers (both occupations that would have contact with poor people with TB), I assumed she had ordinary tuberculosis.

But the article stating she may have caught bovine Tuberculosis does interest me: No, I have never seen a case of that...although about 2 percent of TB cases in Latin America are bovine in origin... 

The reason it is rare today, because cows are tested for TB.