Thursday, May 31, 2012


The difficulties that we used to  face in treating TB were stories in the past if we get patients in our office. We still continue to have problems when we treat patients with TB who are homeless or alcoholic or unreliable. But the case that I am going to describe is difficult due to other reasons.
    I saw this young lady , may be about 40 years old . She was referred to me due to the x-ray findings . She had history  of positive skin test for the TB called PPD . The positive test means that some one was exposed to TB and that caused skin test for the TB to be positive. The test does not mean that patient has active TB .Her x- ray showed the upper lobe abnormality , which was consistent with 'old TB '. She worked in a extended care facility where she worked as physical therapist. So it was essential to rule out active infection with TB . So I did a bronchoscopy and send the samples for the culture of the TB.The cultures came negative --no TB . She was cleared to work in the facility.
   I continued to see her . I had to clear her every year. So I continued to do yearly x-ray and see her every 6 monthly in the beginning and then yearly.
   It must be 3rd or 4th year that we did chest x-ray and it showed some change in the upper lobe , same place where she had scars in the past suggestive of old TB . When she came for the follow up , I asked for any symptoms of the TB , like weight loss or night sweats or low grade fever etc . She had no symptoms. I was still not happy . So I decided to do again a bronchoscopy . The bronchoscopy was done and about 2 weeks down the road I get a call from the microbiology lab . that the bronchoscopy washings were growing TB. I did the bronchoscopy to rule out TB , I was still  stunned. I asked the lady if this was reported to the  the health department . She said 'yes and that it is automatic.I was going to call patient. It was 4-15pm and I had to clear messages . But it was very important to call the patient and the health department. I called the patient and there was answering machine. I left brief message to have her call me . Then I called the health department and I again got the message . I again left the message . I was trying to return my other messages , when I got the call from the patient . I explained her the situation and told her to come to office in the morning to get the prescriptions. She was not alarmed , but was concerned . I also told her about checking the family members . She had a young daughter and husband . They both will be needed to be tested . I also told her to expect a call from the health department . I told her that they will check her out as well as treat her and the family , if needed. They will also monitor them . then I got second call . This one was from the health department and she took down all the information and told me that they will contact the patient and the family in the am and 'take care of this .'
    Up till now this was all expected . But next call was not anticipated. I knew that she worked in the nursing , but had forgotten about it . My next call was from the nursing home director . The patient had informed them about the diagnosis and told them that she will not be in position to work till was on treatment for 2-3 weeks . The director wanted to know about the patients that she was treating and if they should be tested. and what was the 'risk' of transmitting the TB . I tried to explain her the risk but was not able to tell her enough to calm her down . So I gave her the telephone number of the Health Department and told her to contact them in the morning  as  they will be  doing all the testing of the contacts'
    The good news as it turned out , was that the patent's husband , the daughter were all negative  , and the nursing home contacts were also negative . I have since done follow up on her , she is off the treatment and she is fine and the x-ray is good too .

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