Don't forget about Tuberculosis

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.

cross posted from my main blog.