Thursday, May 10, 2012


     I am often asked if the incidence of TB is on rise ? I think it is  on the rise and there are more cases of TB which are drug resistant, TB bug has become more resistant to the 'usual ' medicines that we use. This has to do with the immigration of people to US from the countries that have higher incidence of the TB and so the TB bug from those countries have been 'exposed ' to these anti TB medicines and so have developed the Resistance. But the difficulties that I am talking about are different. So I am going to describe 2 cases here that are interesting.
     I saw this young lady , for the chronic cough. She was 28 years old and had the cough for about 2 months . She saw her primary care physician in the office , who did some blood work and did x-ray and gave her an antibiotic . She was told that she had bronchitis .When she continued to complain of the cough, she was given an another antibiotic .The cough continued , so she was refereed to me .
    She was not short of breath, had no fever and no other complaints . She sounded clear . i.e. lungs were clear . There was some history of cough getting worse with laughing. She was told that x-ray was OK and so I did not repeat it . I ordered pulmonary function studies and started her on bronchodialator. She felt better but still had cough. I had requested the x-ray report but never got it ,So I finally asked her to get the actual films. As the cough continued  I decided to do the bronchoscopy . Her blood tests for allergies were negative . On the day of the bronchoscopy I got the x-ray films . THEY WERE NOT NORMAL , they showed mild 'infiltrate' ( congestion ) in right upper lobe . I thought that she may have had pneumonia and decided to repeat it after the bronchoscopy. and if needed to do the CT scan. . She had the bronchoscopy and it essentially OK . I told the patient the plan to repeat the x-ray and if need  to do the CT scan . And then it happened . I got a call from the micro. lab. that the bronchoscopy washings were growing TB bacteria. .Normally this triggers a call to the patient,then I talk to the patient , start them on medicines and do office follow up in less than 7 days . I also  get the family checked out from the health department. This is not that difficulty.and normally the patient is treated well . Unfortunately in this case there were complications.
     The next day I got 3 phone calls . 2 were from two different lawyers. One was this patient 's employer . He was quite concerned about the exposure of the other coworkers to this patient with TB and what is the risk, what can be done , when can patient return to work , and how sure I was that she will not be spreading the TB.
    The second phone call that I got was from the patient, she was upset and and was mad too . Her soon to be ex-husband and his lawyer were accusing her of  of purposely trying to spread TB to her daughter. I was not too sure as to what this exactly meant, and what was my 'role 'in these accusations . When I got the call from her lawyer it became clear . My patient did not know about the diagnosis of the TB which was in the 'infectious ' sate , and so she still had a close contact with her daughter. So the 'claim ' was that she was hugging her and kissing her with the 'intention ' of spreading the TB and was not 'fit ' yo be the mother and so the husband should get the custody .
    I had hard time trying to sort this out and deal with 3 lawyers and emotionally upset patient . However everything worked out . I told the her employer lawyer that she was 'infectios' for the period of 2 weeks after the treatment was started and was infectious before that too , though 'causual 'contact at work should not cause spread the TB , but testing the close contact workers was the best idea and was recommended.I told the husband's lawyer that she was not aware of the diagnosis of active TB and her daughter was exposed anyway and need to be tested and or treated . This was mandatory as all the family members must be tested . I assured the patient and her lawyer that the husband can not 'use ' TB diagnosis against her .and I will help them if they try to use it .
      The patient was started on the treatment, and was followed by the health department and good news was that she did not have 'drug resistent' TB and her daughter was negative for TB on further testing and her co-workers had no problems as far as I know.


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