Hateful Tb

Tuberculosis.  Even the word sounds bad. 

I remember reading in Time magazine a few years ago about the resurgence of tuberculosis and the development of resistance to the medications that we have to treat it.  In the developing world and the HIV population, it is a very real problem - and those two worlds intersect here in Kenya.  Our HIV population is smaller than you might imagine - about 6 percent of our pediatric inpatient population.  Many of them have tuberculosis or have been treated for it in the past.  But, it is not just a problem of HIV infected patients - many of our patients come in with chronic coughs which make us suspect Tb.  I say suspect, because it is actually difficult to confirm Tb in children here.  All children get the BCG vaccine for tuberculosis as infants, and that can muddy the waters when interpreting the skin test that you are all probably familiar with.  That skin test is not even available to us here in Kijabe.  Chest xrays are standard in the work-up of cough/shortness of breath/oxygen requirement, but CXRs are only shadows and cannot confirm the diagnosis of Tb.  Sputums are difficult to obtain on infants and young children.  Gastric aspirates are possible here, but they end up being difficult in practice and are often not confirmatory.  We can occasionally pursue other testing in Nairobi, but those sources are not routine. 

I am just setting the stage for you about how difficult it can be to actually diagnose this common and potentially devastating infection.  Is it treatable?  Yes, very often.  Is it a simple treatment?  No, definitely not.  The standard regimen is to begin on 4 drug therapy (plus pyridoxine, to prevent some side effects of the medications).  This must be taken daily for 2 months, and then you can back down to 2 medications.  Tuberculosis is a tricky germ and, if you use only 1 or 2 or even 3 drugs, it can easily develop resistance.  If the children are infected, often you need to test the parents to see if they need to be treated also.  Taking medications for this long can be difficult for a family (it is difficult for us to remember medications in our family!), and these medications are hard on one's body.  So, you don't want to start someone on the medications, if you don't really think they have Tb....but it is difficult to confirm and you don't want to miss it and have it spread in the body and worsen.

Students learn in medical school that Tb can be anywhere in the body.  Here, we have most often seen it in the lungs, meninges around the brain, and bone.  We use the abbreviations PTb (pulmonary Tb) and TbM (Tb Meningitis) commonly.  We admitted an 8 month old child last week with a 5 month history of cough and a suspicious chest xray.  Mom denied any exposures to people with known Tb/chronic cough, but you have to take that with a grain of salt.  After 2-3 days of "regular" antibiotics for a possible bacterial pneumonia, I started him on the 4 drug Tb regimen (RHZE) because everything about him pointed to Tb.  That one was a pretty easy decision, and I am hopeful that he will do well.

Two other boys with Tb (or probable Tb) have been heavy on my heart this week.  One is a little boy named Jonah, who has Pott's Disease or Tb of the spine.  He is about 8 years old and was brought here from northern Kenya.  He is from the Samburu tribe and does not speak English or Kiswahili, so verbal communication is difficult.  However, he is a sweet little boy who would smile and wave through the window of his hospital room when he saw me and many others coming down the hall.  Tb of the spine will eat away the bones and cause collapse of the vertebrae, resulting in a gibbus formation and "hunchback."  Jonah's condition was advanced and he could not walk.  I have learned, though, that once the infection is treated and the spine is stabilized, these kids often heal well and the overwhelming majority are neurologically normal - walking!  The goal with him has been to treat with Tb meds, debride the abscess around the spine, and stabilize the spine with rods/bone grafts. 

His surgery was difficult due to hypotension (very low blood pressure) and an episode of circulatory collapse but, after 3 trips to the OR, his infection was drained and the spinal cord fused.  We are all waiting and praying that he will wake up and be neurologically normal - first, his brain after the cardiac arrest that he experienced during his second surgery, and secondly, that his lower extremities will function.  For the full, eloquently written story, see Mike Mara's blog (orthopedic surgeon) at marasafari.org.

The second boy is named Vincent.  There are some things in life that just don't have an explanation.  We see many things here in Kijabe that just "shouldn't happen,"  and this is one of them.  He is a 15 year old boy - about Ted's age - who has been having weakness for a few years, and has not been ambulatory since January.  He is from a large family without resources, and he did not receive proper treatment.  He may have Pott's Disease too - many elements of his presentation are similar to Jonah's:  hunchback on exam, vertebral collapse on MRI, etc.

The big difference is that, because he lay in bed without proper cushioning or rotation, he has developed enormous pressure sores on his buttocks.  I can't post photos of this, because it is just too horrifying.  It is horrifying to me.  I held it together while examining the wounds Saturday morning, but couldn't control my emotions when I got home.  The left ulcer shows the ball of the femur totally exposed and is some 10 inches or more across.  He is depressed, weak, paralyzed, and in pain.  If only I could turn back the clock to before these pressure sores developed and treat him....if only I could stretch new healthy skin and tissue over these gaping wounds....if only Jesus could touch him.  Jesus can heal him - with one touch or slowly over time.  But I feel helpful to care for him - he cannot have spinal surgery until his pressure sores heal, and really that is secondary now.  His wounds are growing a multi-drug-resistant bacteria called Klebsiella, and he is terribly malnourished which prevents wound healing. 

He should be in high school and playing sports with his friends, like my son.  I can offer no logical explanation of his situation, and it grieves me to even think of him.  Please pray that his infections will respond to the many costly medications and that he will eat and gain weight.  Please pray that his pain is tolerable and that he truly has the will to live and cooperate with his wound care and conditioning.  Please pray that he truly knows Jesus.

Love,
Sarah

Matthew 9:36-37
And Jesus went throughout all the cities and villages, teaching in their synagogues and proclaiming the gospel of the kingdom and healing every disease and every affliction. When he saw the crowds, he had compassion for them, because they were harassed and helpless, like sheep without a shepherd.