day 7: adventures in N95-mask wearing

after a fairly uneventful (but eye-opening) first day and an (unfortunately) eventful second day, marybeth and i entered edendale on wednesday without a sense of expectation apart from our eagerness to continue to learn and experience new things! today proved to have a theme which will likely permeate through most of our days here: tuberculosis.

what do you know about TB? at columbia, many of us have seen at least a handful of cases of TB in our immigrant population. did you know that according to both CDC and WHO, TB is one of the world's deadliest diseases? they estimate up to 1/3 of the world's population is infected; that last year alone, ~9 million people became infected and 1.3 million died (www.cdc.gov). the most recent US data: 9,945 cases in 2012 (3.2 cases per 100,000 people); over half of these cases (63%) were in foreign-born people living in the US. in south africa, 1% of the entire population contracted tuberculosis in 2009: 139,468 (949 cases per 100,000 people). additionally, there is >70% co-infection rates with both HIV/TB (HIV being a topic for another day; >30% of south africa's population is infected with HIV, the highest rate on the entire continent). in south africa, specifically kwa-zulu natal province (where we are located), multi-drug resistance (MDR) and extensively drug resistant (XDR) TB have emerged and are huge problems; this has much to do with late detection and incomplete treatments. (www.un.org/milleniumgoals/aids.shtml).

it is within this population that we work each day; although stuffy & claustrophobia-inducing, we don our N95 respirators religiously in the hope that we won't inhale too many tuberculosis bacilli to become infected ourselves. today's morning report case was a fairly common case: a young gentleman with weight loss, cough, and upper lobe findings on his CXR for whom the overnight medicine registrar could have diagnosed tuberculosis in her sleep (and might have!). the reason it was presented at morning report was not to highlight a rare diagnosis (as we do at columbia), but to solidify for interns and registrars the management of sensitive, MDR, and XDR disease. i was absolutely fascinated; for me, this was not solidification of knowledge, but a whole new realm to explore. (i'm sure the budding ID specialist in me helped with the fascination part; some of you might be nodding off now...)

morning report today: pretty routine (for edendale) case of pulmonary TB. if you look closely at the board, the discussion surrounds MDR and XDR TB -- what they are and their risk factors.

as if to highlight the above discussion, we spent the day with several registrars in the triage area of what is usually the medical outpatient department (MOPD) which was closed from the day prior's sewage leak. we encountered at least 5-10 patients with either confirmed or suspected TB. one gentleman seemed to highlight the above discussion too well: a strikingly cachectic zulu-speaking man in his 70s, perched on a wheelchair, a simple face mask placed haphazardly over his face whilst he coughed heartily around it without regard to his neighbors. on review of his chart, he had been diagnosed the prior year, prescribed therapy, and promptly stopped taking it for unclear reasons. he presented to the clinic on this particular day for what he described in as many words as blood-streaked sputum. did he now have MDR TB? maybe (although we joked he may not have even taken enough of the therapy initially to induce this). how many people might he have infected over the past year coughing, coughing, coughing not on therapy? likely many. the registrars admitted him to reinitiate therapy, and we all kept our N95 respirators snug on our faces for the next few minutes... uneasily taking them off sometime later knowing that TB particles can remain in the air up to 6-8h after they're coughed there. 

posters all over the clinical areas act as reminders of the MDR drug regimen adopted in south africa.

although pulmonary TB is a commonplace diagnosis here, extrapulmonary TB is equally as common with varying sites of infection, especially given the high prevalence of co-infection with HIV. already, i've encountered patients with miliary TB, massive pleural effusions requiring chest tube drainage, scrofula (tuberculous cervical lymphadenitis), several cases of TB meningitis, and a fontal lobe tuberculoma. another clinic patient this morning was evaluated for gastrointestinal TB; i'd expect more pott disease (spinal), however the lack of availability of imaging likely limits this diagnosis and it may be more prevalent than can be identified.

looking forward to learning more about tuberculosis this month -- and the multi-faceted approaches to start controlling the epidemic. here's hoping my N95 stays snugly on my face and my fascination doesn't lead to seroconversion!

until next time,
sharon