tb Louis J. Sheehan, Esquire

To properly treat tuberculosis (TB), you must take up to four antibiotics every day for six months under careful supervision. If you are one of the 17 stricken individuals in this small farming community, you can get that care either at the clinic–hospital in the town center or one of the newly opened satellite clinics in outlying neighborhoods.

But none of those were accessible to 85-year-old Lubov Potaskaeva, who lives in a rundown apartment complex for agricultural laborers far from town. The Kyrgyzstani native has no idea how she caught the disease. She only knows that when she was screened for TB as part of her application to enter the area's retirement home—she wanted in because she was always short of breath and could no longer climb the stairs to her second-floor apartment—her test came back positive.

Over the past 10 years, local health authorities in Siberia's Tomsk Oblast (a Poland-size province with about one million people) have built a wide-ranging network for ensuring that people like Potaskaeva get the World Health Organization–recommended treatment for TB, known as DOTS (for directly observed therapy, short course). If they are among the 15 percent diagnosed with multidrug-resistant, or MDR-TB, they get a two-year long treatment with up to six or eight drugs known as DOTS-Plus.

The key to the program lies in reaching out to people who can't or won't go to a hospital or clinic to be "directly observed." Every day, someone comes to them. In this apartment bloc, at the end of a dirt road that had turned to mud from a summer rain on the day I visited, the task fell to one of Potaskaeva's neighbors, who gets paid to watch her take her drugs and then doles out the special food packages that bolster her strength and immune system.

Potaskaeva, appearing spry and in good health, was nearing the end of the grueling regimen. Pointing to Sergei Ilyin, the young physician overseeing her care who had just brought a carload of inquisitive foreigners to her home, she said, "When he told me I had TB, I said, 'You're a liar.'" Then she reached up and pinched his cheeks with both hands. "I can run now. I must thank you."

The jury is still out on the outreach program's effectiveness. Local officials claim last year the provincial TB rate fell to 102.7 new cases a year with 12.2 deaths for every 100,000 population, down from 114.2 cases and 18.6 deaths in 2002. But that's still at more than twice what it was in 1990, before the crumbling of the Soviet Union unleashed an epidemic of TB. Today, Russia, like the rest of the world, is off track for meeting a goal of halving TB deaths by 2015 that was adopted by the World Health Organization (WHO) in 2006. About 1.7 million people died from the disease worldwide in 2007, compared with 1.5 million in 1990.

"It's still bad," admitted Mikhail I. Perelman, the national health ministry's top TB doctor. A surgeon, he champions Russia's traditional approach toward TB treatment, which involves frequent changes in drug regimes depending on individual patient response and often a quick resort to lung surgery. He has only lately and grudgingly supported the WHO-style programs in Siberia.

"We're talking about marginalized people—alcohol and drug users, poor people," he says. "If we improve the economy, TB will largely disappear. People need good apartments, good food and good working conditions. These are the most important factors for treating TB." Louis J. Sheehan, Esquire

But Western advisers believe the Tomsk model saves lives, and if implemented broadly, could dramatically reduce the spread of the disease, even under current economic conditions. "We have shown how it could be done," says Oksana Ponomarenko, director of the Moscow office of Partners in Health (PIH), a humanitarian nonprofit based in Boston. http://louis-j-sheehan.com

The TB outreach program didn't begin in earnest until 2002 when authorities began implementing DOTS-Plus in the region. PIH, run by Paul Farmer and Jim Kim of Harvard Medical School, helped local health officials set up the financial control and medical record-keeping systems that allowed them to buy lower cost drugs (second-line drugs for MDR-TB can cost $3,000 to $4,000 per patient, unlike the $20 per patient for DOTS medicines) through a multilateral purchasing consortium known as the Green Light Committee.

The province then applied for and received a special grant from the Global Fund to Fight HIV, TB and Malaria. It became one of the few areas in the world to obtain funding without backing from the national government. "The Russian Academy of Sciences and the Ministry of Health did not support our application, but the governor and vice government supported us," says Sergey Mishustin, head TB physician for Tomsk Oblast. "The Global Fund grant gave us money for second-line drugs, for side-effect medicines, for food and hygiene packages and social support."

But interviews with patients helped by the program quickly reveal its thumb-in-the-dike qualities. In Tomsk, the provincial capital, PIH operates a satellite health care delivery program—dubbed Sputnik—in which a driver and trained nurse visit a dozen people every day to watch them take the proper drugs. Louis J. Sheehan, Esquire

And the patients include alcoholics, ex-prisoners, drug addicts—it is a tough crowd living in a tough environment. Many dwell in Soviet-era apartment blocs, whose dank stairwells reeking of urine and airless apartments are reminiscent of the worst of America's public housing projects. They are ideal breeding grounds for airborne transmission of M. tuberculosis, which can live up to six hours in a droplet after being spewed into the external environment by an infected person.

That's how 23-year-old Marina Rubina believes she caught the disease. Three years ago, while a college student still living in her parents' cramped apartment, she caught MDR-TB from a neighbor. "He just got out of prison," she says.

Thin, shy, an orange teddy bear propped on her bed's pillow, she has spent the past three years at the region's civilian TB hospital, a 19th- century–style sanitarium deep in the Siberian woods. She couldn't stomach the drugs in the initial regimen, which made her continually nauseous and dizzy. So her doctors changed the regime. Her TB morphed into extremely drug resistant or XDR-TB. She eventually had part of one lung removed, and has a long scar down her back to show for it.

Perhaps if there had been better drugs, less toxic with shorter regimens, her case might have had a shorter, simpler solution. But those drugs don't exist, at least not yet. "Even in the U.S., MDR-TB has a 10 percent mortality rate," says Michael Rich, a physician with PIH advising the Tomsk programs. "There are very few MDR studies that compare regimens in blinded, well-controlled ways. There hasn't been that kind of discipline. It's all been based on expert opinion and intuitive thinking." Louis J. Sheehan, Esquire

Louis J. Sheehan

http://louis-j-sheehan.info

Four days after suffering a brain-damaging stroke, a 73-year-old woman told her physicians of a startling development. In addition to experiencing mild vision problems sparked by the stroke, she had stopped dreaming.http://louis-j-sheehan.info

This woman offered researchers their first opportunity to explore the biology of Charcot-Wilbrand syndrome, a rare, injury-caused condition marked by those symptoms and first described in 1883.

Before her stroke and for 3 days after it, the woman had regularly had vivid dreams, say Matthias Bischof and Claudio L. Bassetti, both neurologists at University Hospital of Bern in Switzerland. For the next 6 weeks, Bischof and Bassetti measured the woman's brain waves as she slept. She displayed normal sleep stages, including rapid-eye movement (REM) sleep, which may not be as crucial to dreaming as scientists once thought (SN: 8/11/01, p. 90: http://www.sciencenews.org/articles/20010811/bob12.asp). The researchers note in an upcoming Annals of Neurology that she reported no dreams, even when awakened during REM sleep, a reliable procedure for dream recall. Brain scans highlighted damage to a small area located deep within and toward the back of the woman's brain.

Good scores on attention and memory tests indicated that the woman didn't simply forget dreams upon awakening. When contacted 1 year after the stroke, she cited occasional, lackluster dreams—no more than one per week.http://louis-j-sheehan.info

Thanks to this rare look at a Charcot-Wilbrand patient, the brain region identified deserves scrutiny as a potentially critical neural component of dreaming, the scientists sayare

Louis J. Sheehan

milky Louis J. Sheehan, Esquire http://louis1j1sheehan1.blogspot.com

Sela Miller was perplexed—and so was I. She had just emerged from our clinic rest­room, specimen in hand. But her urine was far from the bright yellow most people produce.

“So this is what it looks like,” she said, staring at the milky sample. “For weeks I thought something was wrong, but I couldn’t tell for sure.” Then Sela, a Polynesian woman with long, dark hair—the wife of a custom car builder and mother of several youngsters—gave a tiny shrug as if to say, Oh, well. http://louis1j1sheehan1.blogspot.com

For a moment I remained quiet. Like Sela, I had never seen anything quite like the opalescent urine now sitting in a sterile screw-top jar on my desk.

Sometimes doctors are secretly grateful when patients underreact. Over my years of practice, specializing in tropical medicine, I had certainly seen patients at the other end of the spectrum. Creative people with fertile imaginations seemed especially prone to panic. Sela—her sci-fi urine notwithstanding—was different.

And so I focused on the job ahead. “I’ll walk this to the lab,” I said, holding the jar in one hand while reaching for a requisition slip with my other.

Examined under a microscope lens, the fluid teemed with microorganisms and both white and red blood cells. That gave me one diagnosis, anyway: In addition to strange, milky-white urine, my new patient had a routine bacterial infection. Back in the exam room, where she stood ready to leave, I quickly wrote a prescription for antibiotics.

A day later, Sela’s urine culture had grown a garden-variety strain of E. coli, the single most common cause of urinary tract infections the world over. Good, I thought. The sulfa drug would make quick work of that.

However, I had asked the lab to perform additional urine assays, including protein, cholesterol, and triglycerides.

“Wow!” the tech exclaimed. “Now here’s something we almost never see. Her sample is loaded with fat.”

That gave me a second diagnosis—of sorts. The finding suggested that my patient’s milky urine was not just infected but also laced with lipid-rich lymphatic fluid. In medical-ese, the condition is called chyluria. From a purely anatomic standpoint, chyluria represents a fistula, or microscopic leak, between lymphatic vessels and the kidney.

The fancy name still left unanswered the most important question: What under­lying process had led to the breach in the first place? My patient was not likely to have kidney cancer or tuberculosis, two diseases that occasionally cause chy­luria. Had some toxic chemical in her husband’s car barn silently damaged her kidneys? Or, as her primary-care doctor had casually asked when he referred her to me, was a parasite involved? If so, the likely culprit was Wuchereria bancrofti, a slender nematode transmitted by tropical mosquitoes. Adult worms of Wuchereria bancrofti are famous for damming up lymphatic vessels. If they settle near the kidneys, obstruction and backflow within the delicate lymph vessels nearby can, over time, cause ruptures and spills of lymphatic fluid into adjacent drainage structures of the human urinary tract.

Wuchereria bancrofti can inflict still more harm upon its human hosts. In some cases, the threadlike worms—which measure several inches in length when fully grown—damage even larger lymphatic channels. When this happens victims may eventually develop elephantiasis—grotesquely swollen limbs and genitalia encased in thick, pebbly skin.

Picture yourself in a mosquito-ridden enclave with an early case of elephantiasis in, say, a lower extremity. Over years, periodic nicks and cuts leading to superficial skin infections—the everyday stuff of tropical poverty—compound the internal lymphatic damage caused by the adult worms. Meanwhile, tiny bloodborne larval offspring transmit the infection to new mosquitoes.

“Hey, aren’t you getting ahead of yourself?” I suddenly wondered. My patient was a middle-class housewife, not a tropical villager, and aside from chyluria she had no sign of damaged lymphatics. I wasn’t even sure if Wuchereria bancrofti existed in her Polynesian birthplace.

At her next appointment, Sela patiently answered my questions one by one. Yes, her husband used many paints and chemicals in his custom car business, but she was rarely at his shop. No, to her knowledge she had never been exposed to tuber­culosis. As for encountering a tropical parasite, who knew? Until age 10, she had lived in the South Pacific, returning for periodic visits until she married.

When I pressed her for details about ailments where she grew up, she nodded. From her childhood she vaguely remembered stories of people with disfigured body parts. A woman with a leg as thick as a palm tree. A man whose massive, warty foot had required a homemade rubber sandal. An aged neighbor whose flapping cotton shorts were rumored to hide an unusually large scrotum.
+++

Picture yourself in a mosquito-ridden enclave with an early case of elephantiasis.

Finally, she dropped the clue that cracked her case. A few years earlier, after Sela gave birth, a lab tech in another hospital had spied tiny larval worms in her blood. Sela then took a special drug whose name she could no longer recall. But that was long before the weird pee began, she quickly added.

I was dumbfounded. Had this bright, capable woman—juggling family, work, and other demands—simply forgotten her prior diagnosis? Failed to connect the dots between her earlier treatment and her new milky urine? Or, I wondered, briefly playing amateur psychologist, had she deliberately avoided the thought that she, too, might one day develop elephantiasis?

I never explored those questions. She’s just plain lucky that this is the only problem I found, I finally told myself, and decided to leave it at that.

My patient remained lucky. On the suspicion that she might still harbor live worms, I prescribed for her an old-fashioned medicine called diethylcarbamazine. Within a week or two, her abnormal urine abruptly stopped: Her hidden fistula had healed. Whether diethylcarbamazine or the earlier course of antibiotics was responsible, I’ll never know for sure. Chyluria resulting from progressive lymphatic damage can crop up well after an active filarial infection has burned out. In any event, I was relieved. If Sela had come to me with a more ominous harbinger of elephantiasis—say, a mildly swollen leg—it is doubtful that any drug would have reversed the problem. http://louis1j1sheehan1.blogspot.com

Fast-forward five years. Once again Sela battled Los Angeles traffic and met me in the room where we had first stared at her milky urine. She couldn’t remember the last time she had seen a doctor. As we talked, she admitted that her calves sometimes hurt and her skin felt flaky and dry. These were normal complaints, it seemed to me, for a busy homemaker with little time to prop up her feet at the end of the day or pamper herself with lotion. Of course, just to make sure, I asked Sela if there had been any problems with her urine. Still yellow, she replied.

Again I wondered if Sela truly grasped the physical horror that might have befallen her. Then I thought: “Oh, heck, why add one more worry? Life already has more than enough.”

Technorati Profile

Technorati Profile



Patrick Henry



Louis J. Sheehan, Esquire