Skip to Navigation

Tuberculosis (transcript)
Share This:

(NARRATOR 1)  
Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association.  An association of independent locally owned and community based Blue Cross Blue Shield plans committed to better knowledge for healthier lives.


(clock ticking)

(heart beats join in)

(music joins in)

 


(Dr. Peter Salgo) 
Welcome to Second Opinion where each week our health care team solves a real medical mystery.  When we close this file in a half an hour from now you'll not only know the outcomes of this week's case, you'll be better able to take care of your own health care.  I'm your host, Dr. Peter Salgo and you've already met our special guests who are joining our cast of regulars, primary care physician Dr. Lou Papa and communications expert, Kathy Cole-Kelly. 

Now, no one on this team knows the case... except me. I've got it right in here and I'm going to give it to you a little bit at a time. 

Let me tell you about our case.  It's about Timothy.  Timothy is a 74-year-old gentleman.  He has been married for forty-eight years, has two grown children, six grandchildren and the children live out of state.  He has worked as an insulation maker for forty-five years and he's now retired.  He lives in a large city.  His wife and he have an active social life.  He heads up a network of Korean War veterans in town and he's very active in the community.  Now, for the past few weeks Timothy has been experiencing shortness of breath and chest pain every time he mows the lawn and he also has a nagging cough, so as is typical with guys he ignores it but finally he talks to his wife about it and she as is typical of wives says get something done about it and they call the primary care physician.  The primary care physician says don't come to my office now that I look at this and says you go to the emergency room and I'm going to meet you there.  Lou, is this primary care doctor over-reacting?

(Dr. Lou Papa)  
No, I don't think so. You have a 74 year old man who has exertional shortness of breathe and chest pain and your first concern is, is this a cardiac event?  A little unusual with a cough, but that can happen, that is the first thing that I'm concerned about.

(Peter) 
But you can have a cough with heart disease can't you?

(Dr. Michael Iseman) 
You surely can.  It's very difficult.  It's not the exclusive prominence of lung disease.  Priority-wise, though, lung disease can generally wait; cardiac disease can't.

(Peter) 
You take your other killer items first, so if you were in the emergency room or Lou, you are in the emergency room, for example, what are you going to do first?

(Dr. Paul Levy)  
Well, the first thing with those symptoms would be vital signs, stabilization and a cardiogram.

(Peter) 
All right.  I can tell you what the cardiogram showed.  You know it's normal.

(Lou)  
Has he had any past medical history at all?

(Peter) 
Well, his past history is that he's a non-smoker and he was diagnosed with silicosis five years ago.  What on earth is silicosis - anybody?

(Dr. Paul Levy)  
I'm assuming this came up with his employment as an insulator working with products that probably contain silica.  That's a pneumoconiosis which is a term for inhalation of the silica particles, silica dust, which eventually as they can accumulate cause lung injury.

(Peter) 
So they get an x-ray and the x-ray, as you might expect, shows innumerable teeny weenie pulmonary nodules.  However, it also shows what's called a soft tissue density in his right upper lobe, which is up here.  Something pretty thick is going on, not these tiny little nodules that would I think be typical of silicosis.  It also mentions there's something called hilar adenopathy which is the lymph nodes in the center of his chest x-ray are big and some of these lymph nodes have calcium in them.  At this point, Lou, what's going on with Timothy?

(Lou)  
It really broadens things out a little bit.  Even though the EKG is normal you still worry about ischemia, not necessarily an influx or you have to keep that in the back of your mind.

(Dr. Peter Salgo) Ischemia meaning heart disease.

(Lou)  
Meaning heart disease, but the chest x-ray changes because he has this history increases the risk for things like lung cancer.  Increases the risk for certain infectious agents especially with the lymph nodes that raise a concern in my mind.

(Peter) 
So, Timothy gets admitted to the hospital.  He has a full cardiac work up.  All of his tests come back normal and you're called, or your equivalent, the lung doctor, the pulmonologist, because, after all, the abnormal thing here is the chest x-ray.  What are you going to do at this point?

(Dr. Paul Levy)  
Probably the most important piece of information to decipher the acute versus chronic is the old x-ray.

(Peter) 
His old x-ray does show - this is from five years ago - silicosis.  Lots of tiny little nodules.  His lung doesn't look significantly different from the old one except for this right upper lobe process.  They're a little concerned because in their view they write this doesn't look like the progression of silicosis to us.  They send off some sputum and they send it to the laboratory.  They send it for cytology, for AFB, they note, and they've scheduled a diagnostic bronchoscopy.  They tell Timothy they're trying to make sure he doesn't have cancer.  So, let's examine these things that they sent it off for.  What's cytology?

(Paul)  
The cytology specimen is, again, thinking about what that x-ray must have looked like; perhaps there was a mass-like infiltrator or a mass-like shadow.  The cytology in the sputum would help you with a diagnosis of malignancy, that is, lung cancer.

(Peter) 
And the kids, by the way, as soon as that word was out flew in to be with dad.  The chart indicates that the doctors all come back in and they look a little different because all the doctors are wearing masks and they said you are now on isolation.  Your family has to leave because what we found in the laboratory on your sputum was tuberculosis.  What's going on here?

(Michael) 
I think by his age and by the experience in the military and by having silicosis, all those take him to a much higher risk for TB.

(Peter) 
Define TB.  What is TB?

(Michael) 
TB is an infection caused by a bacterium, not a virus.  The bacteria belong to a family called mycobacterium.  It's from the Greek word for ray.  It's a rod-like organism.  It originally came out of the soil and they have real tough cell walls to have survived in the soil, which allows them to float in the air and resist dehydration.  It's transmitted patient to patient and it is a historical and contemporary ongoing epidemic that we don't appreciate here in the U.S.

(Betsy McCaughey) 
And most Americans, at least people who are born here, don't worry about TB.  It was the white plague for centuries, but until recently most people at least thought the United States had eradicated TB.  That's not true any more.

(Peter) 
Who gets TB?

(Michael) 
In the world TB is devastating in India - two million new cases a year.  China, a million new cases a year.  The highest case rates in the world are in southern Africa, Russia and the former Soviet Republics.  Here in the industrialized nations we are relatively spared TB.  It is disproportionately seen in America among immigrants and minorities.

(Betsy) 
It's most prevalent in cities because the case number is increasing among the foreign born whereas among those who are born in the United States it's decreasing.

(Dr. Peter Salgo) 
But I want to go back to Timothy.  He didn't cough; he came in with shortness of breath and chest pain.  Is that typical?

(Paul)  
What you're describing is classic for tuberculosis.  It's a diagnosis that we often back into, meaning that we don't think of it first or second or third.  It's on the list of possibilities, but because it's so uncommon here in the United States you often think of cancer, lung cancer, or other problems in the lung first because they're much more common.

(Betsy) 
Because it takes so long sometimes to properly diagnose a patient and because patients often live with these symptoms for a long time before even seeking help, the average TB patient imparts the disease to ten or twelve other people before being properly diagnosed.

(Lou)  
But it's a great masquerader.  I remember through residency medical school when you're on rounds and the professor asks you a differential - always throw TB in there and sarcoidosis because they can masquerade as anything and they won't classically present as the fevers, the weight loss and the cough, they can present almost any way.

(Paul)  
This is another peculiar aspect of tuberculosis.  You can have patients with the most impressive, foaminate looking form of tuberculosis and zero symptoms and you can have people with some of the most trivial infiltrates, that is, very minimal changes on the film and yet they have night sweats, weight loss.  They feel lousy for weeks and months at a time and there's a real disconnect there.

(Peter) 
Do any of these symptoms sound familiar to you?

(Anne Meade)  
Yes, most definitely.

(Peter) 
And why would that be?

(Anne)  
Because I have had tuberculosis and I actually do have a little hole in my left lung and will the rest of my life. I was exceedingly tired but I was working in a job where it was very demanding.  It was caught because the part-time job I was doing at the time at the hospital and so it was caught on a tuberculin test, but I was very, very tired and I had had weight loss, but had also been under a lot of other stress.

(Peter) 
On a global scale how bad is TB?

(Michael) 
The World Health Organization calculates that one person in three living in the world today has latent infection with the bacterium.

(Peter) 
One-third.

(Michael) 
One-third.  Two billion people.

(Peter) 
Let's just pause for a second and sum up where we are.  We've covered a lot of ground and let's figure out what's going on.  Tuberculosis is a huge public health issue.  It's increasing in numbers worldwide and in certain populations right here in the United States.  Let's continue.  I'm curious about something, which is when we started talking about tuberculosis and later when you said we often back into this diagnosis the assumption was we don't have a lot of TB around here.  People aren't getting it and I think the impression of the population of the United States at large is this is over.  Why isn't it gone?

(Dr. Michael Iseman) 
TB, it has this capacity to exist in the reservoir of people who over time will develop TB who travel from one area to another and then develop TB, so it really has planted seeds of TB in mankind that will presumably bloom or cause suffering and death in the decades ahead.

(Dr. Peter Salgo) 
TB rates in this country were going down very nicely and then something happened.

(Michael) 
Yeah, the history of TB therapy was sanatorium based for the better part of the twentieth century, but even when we had drugs patients went to the sanatorium and were given the drugs and we began to think that's excessive.  We can cure TB without locking somebody up, so we closed down sanatoriums, returned people to the community, but we didn't fund community based programs sufficient to make sure that treatment was delivered on an out patient basis.

(Peter) 
Anne, you had some experience with that.

(Anne)
Yes.  My father was the last director of Trudeau Sanatorium which was the first tuberculosis sanatorium in this country and it closed in 1955, so I grew up living on the grounds of a tuberculosis sanatorium until I was seven and the people were there for years.

(Peter)
You got active TB anyway.

(Anne)  
Yes.  Yes, although many years later.

(Peter) 
The last we say Timothy he was in his hospital bed with his family outside surrounded by masked avengers, doctors with masks on.  Let me ask you some questions that I'm sure Timothy was asking at the time.  Is his family going to go back in the room?  Are they going to let them back in?

(Paul)  
Well, it's kind of an interesting question that comes up.  It turns out the damage has already been done with his immediate family meaning if he has transmitted it to his direct household he did it weeks ago, months ago.

(Peter) 
But remember, his kids lived out of town and they just came in to see him.

(Paul)  
So the new visitors, yes, they may be at risk, but generally in that setting we minimize visitor contact with the indexed patient, that is, the person who has active infection because you don't want new transmission to take place.  Medications would be started promptly on the basis of his x-ray and smear and his infectivity, that is, his ability to transmit it to others plummets rapidly in the first week or so of therapy.

(Peter) 
So you're going to test everybody in his family?

(Dr. Paul Levy)  
What you're referring to is a contact investigation where once you've identified a patient if indeed this is tuberculosis, it's smear positive, you can see it on the smear, you would be going to him and his family to figure out who are all the close contacts he's had over the past several months.

(Michael) 
With TB it is usually weeks and months before there's any manifestation of the new infection unless you are a person with AIDS, unless you are a person with an organ transplant or on chemotherapy or if you're a very young infant.  Those are individuals who after exposure may literally within weeks have life threatening disease.

(Dr. Peter Salgo) 
What kind of contact do you have to have with someone who has active TB to really worry whether or not you've caught it?

(Michael) 
Statistics for public health contact investigations in America year after year show that when we go into a household where there was a case and presumably the case was symptomatic for weeks or months before detection, probably a third of the household contacts are infected.  The organism has a very brilliant strategy in producing disease.  When we inhale it in our lungs it doesn't make us immediately sick.  In fact, in most cases it's delayed by months or years and so the notion is that it takes a long time being exposed in an indoor space to transmit TB.  However, like the lottery, you can buy one lottery ticket and win a billion dollars or however much the Powerball is worth

(group) laughter

(Micheal)
or you can be on the wrong bus at the wrong time and someone coughs and you may lose that lottery.  It's not likely but you can be exposed and infected with a very brief episode.

(Peter) 
Timothy was both shocked and terrified and his first question was why me.  How did I catch it?  Where did I get it and what could you have told Timothy?

(Paul)  
Again, I'd focus on the good news is this isn't cancer.  The good news here is that this is tuberculosis and in fact this is treatable, curable and if you can work with the program this indeed is something that we can get behind us and not have any long-term issues.  Where did he pick it up?  I suspect it was from his military career combined with perhaps the silica exposure.

(Peter) 
The undercurrent of his surprise and his shock I suspect is what could I have done not to get it?  Was there something that I, Timothy, could have done not to get TB and we can broaden this.  What can anybody do to try to minimize the risk of getting this disease?

(Michael) 
The strategy in the United States is hinged around recognizing latent infection.  Things that we have to do, though, is to target in the appropriate groups because we can waste a lot of time and money, get false/positive tests and squander the limited assets we have before not judicious.

(Peter) 
Let's pause for just a moment, if I may, and sum up where we are.  I think it's important to remember that tuberculosis is transmitted through the air and its transmission is promoted by contact.  Close living conditions can promote it, poor nutrition.  A compromised immune system can promote it.  However, as our guests have pointed out, anybody can lose the lottery, if you wish.  Anybody can get it if you're unlucky, so you need to talk to your doctor to find out how often you need to be tested for tuberculosis.

Timothy is still in the hospital.  This has really been a compressed time for us.  They've gotten the diagnosis based on his sputum.  His family's been ushered out. They've told them he has TB.  Given the fact that he does have an active tuberculosis infection what are his doctors going to do for him at this point?  How are they going to treat him?

(Paul)  
First line drugs would be indicated here and that's a multi-drug therapy meaning at least three if not four medications would be started as our first line therapy.  Those are given daily, but four drug therapy, direct observation and after he's been on therapy for about two weeks likely he's going to be able to be released from the hospital and go home from there.

(Kathy Cole-Kelly)
I also hope part of what the physicians do is number one include his wife in these discussions because we have the direct observation, but also having the spouse or the caregiver educated about the disease is much more likely to result in adherence.

(Peter) 
Direct observation therapy.  What is it and why is it important?

(Betsy) 
It's a simple concept.  It means that a caregiver, a medical professional of some sort, actually delivers the medication to the patient and watches the patient take the medication. Some patients don't want to take the medication because of its side effects.  Even more often patients stop taking the medication because they feel better.

(Peter) 
Let's make this very clear.  Noncompliance, which as you point out, is people stop taking their medicine before they should.  Why is that bad?  If they get better, they don't get sick any more, why is that a risk?

(Betsy McCaughey) 
Well, they don't really get better.  It doesn't eradicate the bacteria.

(Dr. Peter Salgo) 
So it's a risk to them.

(Betsy) 
Right.  There's some indication that in some cases it actually creates multi drug resistance or exacerbates it.

(Peter) 
But can we make folks take their drug?  Supposing they say my body, my disease, get out of my face.

(Paul)  
If they actually pose a community health threat, that is, if they have active disease which is contagious and refuse medications under a court order we can do that.

(Betsy) 
Or we can isolate them.

(Michael) 
I'm not sure we can make them take medicines.  I think that's been regarded in some courts as assault and battery.  What we can do is lock them up if they refuse.  They're not like your pet where you stuff the pills in the back of their throat disguised in hamburger.

(Peter) 
Do I hear you saying take the pills or go to jail?

(Dr. Michael Iseman) 
Yes.

(Peter) 
Did you get directly observed therapy?

(Anne)  
No.  I was prescribed Rifampin and Isoniazid - only a two drug cocktail at the time.  This is back in '84.

(Peter) 
By the way, that was before, really, legislated directly observed.

(Anne Meade)  
Yes.

(Peter) 
Just to be clear, they weren't coming after you with handcuffs.  The program wasn't there at the time.

(Anne)  
No, it was not.  I became allergic to Rifampin very quickly.

(Dr. Peter Salgo) 
You have a significant risk.  Greater than someone who completed traditional therapy of getting this disease reactivated. Is that true?

(Anne)  
I would believe in looking at it from this perspective.  That is probably the case.

(Dr. Lou Papa)  
I think there's a big part of this that we're - it's fine if a patient wants to do what they want that's fine, that's their choice.  There's the public health aspect of this and that's one of the things when we talk about it we tell the patient, you come in every day you feel better. I think you have to say to the patient you have a disease that you can spread to others and that's why we need to treat you to completion and although this may make you feel better, the bigger issue - that's part of it.  The other part of it is... are you no longer a risk to the public and that we don't know.

(Peter) 
How successful has directly observed therapy been?

(Paul)  
In New York State, Monroe County in particular where I can give you our statistics, it's impressive. We have a one hundred percent completion rate.

(Peter) 
One hundred percent.

(Paul)  
One hundred percent of patients were able to get through six to - actually, we go nine full months of therapy with multi-drugs.

(Peter) 
It's actually a treatment strategy that works.

(Dr. Paul Levy)  
And in fairness to the numbers when you take patients through D.O.T, directly observed therapy, and you complete. There's roughly at most a two percent chance that you'll have a treatment failure down the road within the first couple of years after stopping.

(Peter) 
I'll be the bad guy over here.  Supposing you've already told us that there's a reasonable chance that your TB will come back because you didn't have the traditional therapy and you didn't go to completion.  Supposing it does. 

(Anne) Um..hmmm

(Peter) We hope it doesn't, but supposing it does.

(Anne)  
It's something that I've definitely thought about.

(Peter) 
You thought about this.  Someone knocks on your door and says it's time for your directly observed therapy.  Here are four drugs. Please come every day.  We're going to watch you take them because as Lou would say the public health demands that.  What would you say?

(Anne)  
At that point since it is the law I would have to comply.  If I was having symptoms, again, I would be squawking about it and trying to make sure that there were other alternatives.

(Paul)  
And what we would do in that instance - not to cut in - is that by having someone see you either daily or if some of these programs can be three time a week, twice a week, but that provider if you had a concern about kidney function and the like, blood tests can be done.  Imaging studies can be ordered and we can make sure we march through this safely to make it as palatable so that we don't harm you, but yet also cure the disease.

(Dr. Peter Salgo) 
Anybody want to know what Timothy's going to do?  He was started on four drugs and Rifampin was one of them, INH was one and he was started on directly observed therapy, but they did something different than I think I heard you say you would do.  They sent him home and basically quarantined him to his home on his promise he would stay there.  He was told and this is written in the chart - we told him if he had company to open his windows.  For two weeks they told him not to go out.

(Michael) 
We know that once the drugs are started probably in most cases within a week they're no longer infectious.

(Peter) 
What's the likelihood that Timothy is going to get better?  Dreadful disease.  Four drugs.

(Michael) 
Tell me what the drug susceptibility pattern of his organism is and I can tell you the likelihood.  If it's a standard drug susceptible strain he has, as Paul mentioned, maybe a ninety-eight percent chance of being cured in a lifetime with six months of medicine.

(Peter) 
I want to pause for just a minute because there are a few other things we want you to pick up before we run out of time, but I do want to sum up where we've been.  I think it's important to remember that tuberculosis is a potentially deadly disease, however, there are antibiotics that work very well for most cases.  Most people who comply with the drug therapy - there's where D.O.T. comes in - are going to get better and they're going to be cured.  So, I want to finally bring you up to date on Timothy.  It's a year and a half later in the chart.  He is better.  His doctors have assured him he doesn't have cancer and his question is can I get TB again and your answer to him would be...

(Michael) 
It's a rare possibility.  We were taught - our catechism years ago was that once you had TB you were immune from it especially if your TB had been treated within your body.  We now know two things happen.  Some patients aren't thoroughly sterilized and they can reactivate their old infection or recent experience from Africa unfortunately indicates that people who had TB two years ago seemed to be at risk of acquiring more TB per capita now than the rest of the population, so it's really turning our model on its head and making us very fretful about how we can control Third World TB.

(Betsy) 
I'm so glad you mentioned that because that really is the biggest challenge facing the United States now, not only in terms of protecting the people who already live here but also assisting the rest of the world.  Now there are these new highly lethal forms of TB.  We've only experienced a small number of cases in the United States.  Almost all of them were travel related, but in other parts of the world from South Africa to Siberia it's a rapidly growing and very serious problem.

(Peter) 
And with that I think we're just going to have to stop the discussion of the coming journal of the plague years.  I don't want to leave without asking you how you're doing.  How are you feeling?

(Anne)  
I'm feeling fine. My health has been very good.  It took a couple of years to get my energy back, but it's twenty-three years passed and everything looks great.

(Peter) 
I want to thank you so much for joining us and discussing -

(Anne Meade)  
Thanks for having me.

(Dr. Peter Salgo) 
Thank you for discussing with us a problem which many people are reluctant to talk about.  I want to thank all of you for being here.  It's been a tremendous show.  Before we leave - we covered a lot of ground today so I want to sum up some of the key things that we discussed. 

First of all, tuberculosis is a huge public health issue.  It's increasing in numbers worldwide.  It's increasing in certain populations right here in the United States. 

Tuberculosis is transmitted through the air and its transmission is promoted like close living conditions, poor nutrition, a compromised immune system.  However, anybody can win the lottery or lose it, if you like, so talk to your doctor to find out if regular testing is indicated for you.  Tuberculosis can be a deadly disease.  However, there are antibiotics that work very well.  Most people who comply with the drug therapy will get better and will be cured. 

And of course our final message is this - taking charge of your health means being informed and having honest communication with your doctor.  I'm Dr. Peter Salgo and I'll see you next time for another Second Opinion.

 

(NARRATOR 1)  
Search for health information and learn more about doctor/patient communication on the Second Opinion Web site.  The address is PBS.org. 


(clock ticking, heartbeats, music)

 

(Narrator 2)
Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association.  An association of independent locally owned and community based Blue Cross Blue Shield plans committed to better knowledge for healthier lives.


(Narrator 3)
We are PBS.