Diagnosis Wenckebach

Another example of medical students with too much time on their hands.

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A laugh while you are on call

TB or Not TB: Isn't That the Question?

The only thing more confusing to me than this tuberculosis (TB) fiasco is how I am still the first to use this line for my title. The antagonist in the international bacterial bruhaha is a young personal injury lawyer who either knowingly or unknowingly flew off to his honeymoon in Greece with a multi-drug-resistant strain of TB (MDR-TB). Actually, the Associated Press reported yesterday that he had an even more resistant strain of Mycobacterium tuberculosis, called extremely drug-resistant TB (XDR-TB). Infectious disease is not my specialty but since when did we start assigning diseases cool prefixes that make them sound like luxury cars? We have heard rumors circulating that the 2008 model will be the YF'd-TB?

So the story goes that an excited newlywed personal injury lawyer goes to the doctor a few days before his honeymoon and is told that he "has TB". Speaker has also said that he was advised by Fulton County, Ga., health authorities that he was not contagious or a danger to anyone. Officials told him they would prefer he didn't fly, but no one ordered him not to, he said.

Let's stop here for a minute. There are really 2 kinds of "have TB"s. There is the positive PPD test for TB in which your body has formed antibodies to Mycobacterium tuberculosis after you have been exposed to it but you are symptom free and otherwise healthy, i.e. latent TB (LTB). Then there is the really have TB in which you are symptomatic, with clinical manifetations usually associated with the pulmonary system. Patients typically present with cough, fever, chills, night sweats, weight loss, bloody sputum, anorexia, etc etc. In this form, one is capable of actively spreading the infection.

Many, many Americans, and even more internationals "have TB" in the former sense and a great deal of them are probably unaware as they have never had a PPD test to detect its presence. And if all of those fliers with latent TB were quarantined, it would probably require a holding room the size of Giants Stadium. But very few Americans with dormant TB ever develop the active form of the disease unless they become immunosuppressed, as in the case of patients with HIV/AIDS or chemotherapy. Moreover, these carriers are not infective to anyone unless the disease becomes active. Lastly, his XDR-TB status does not make his disease any more transmissable than your run-of-the-mill TB, it is just harder to eradicate.

The fact that his new wife and he traveled to Greece makes you think (and hope) that he wasn't hacking up blood-tinged hunks of sputum during his "I do's". Thus, we are making the assumption that Speaker only had the presence of XDR-TB in his blood, making him no different from thousands of other air passengers who travel with latent TB on a daily basis. So what's the big deal? That's what we're trying to figure out. We are guessing all the tumult is a result of him ignoring the Man who told him not to fly.

But where did he get such an uncommon strain of the mycobacteria, that is found much more commonly in Asia and the former Soviet Union? Several reports have claimed that he was exposed when he visited a health clinic last year in Vietnam. We are not disputing that this is a possibility, but it turns out his father-in-law, Robert Cooksey, is a microbiologist for the Centers for Disease Control (CDC) who actually specialized in TB. [The plot thickens...] The same CDC that initiated Mr.Speaker's quarantine - the first of a human being since 1968. In medicine, we have a saying that common things happen commonly and if we follow that theory than it seems less likely that one week in Vietnam accounted for his infection than his chronic and long-term exposure to his microbiological father-in-law.

This is a bold call but we're betting serious money that the wife's father will be investigated and it will turn out that he, too, has XDR-TB (*cue the Law & Order dun-dun). Oh yeah, the father-in-law is the source and he is going down for this in the very near future. Or is he?

Currently, Speaker is taking up residence in a Denver hospital until he is given the green light to travel again. Perhaps we will find out that he indeed does have active TB infection but that will bring up an entire set of additional questions like why a young, healthy man in his thirties develops active TB infection in the setting of a normal immune system. (Dun-dun)