Tuberculosis

Tuberculosis (TB) is a bacterial disease that mainly affects the lungs. In 15% of patients it affects other areas, causing swollen lymph nodes, pleurisy (inflammation of the membranes around the lungs), and meningitis (inflammation of the inner membranes of the brain and spinal cord). It may also affect the kidneys, urinary tract, genitals, thyroid, bones, and joints. TB in the lungs or throat is the most infectious form. In 1993 the World Health Organization called tuberculosis a "global emergency," with an estimated 8 million new cases of tuberculosis each year. Before the discovery of certain antibiotic drugs in the 1940s, TB was the leading cause of death in the United States. Even though there has been an effective public health campaign to stem the tide of rising tuberculosis rates since 1993, it remains one of the most serious public health challenges.

Signs and Symptoms

Usually there is a time delay between infection and the development of full-blown TB. Many who are infected with TB never develop the disease. In some people it is possible for the TB bacteria to remain inactive for a lifetime without ever causing disease. But in others, especially those with weakened immune systems, the bacteria become active. It is also common for those who are infected to be asymptomatic (without symptoms) for several months to years. For example, children are more likely than adults to have no symptoms or to show symptoms in other parts of the body besides the lungs. The type of symptoms will depend on where in the body the TB bacteria are growing. Typically, TB bacteria that grow in the lungs may cause:

• Mild fever, headache, chills, night sweats
• Malaise (feeling unwell), fatigue
• Loss of appetite, weight loss
• Cough, with or without mucus and pus
• Coughing up blood
• Chest pain from pleurisy
• Difficulty breathing
• Swollen glands

What Causes It?

Mycobacterium tuberculosis causes most cases of TB. This bacterium only lives in humans. Two other bacteria cause TB. They are M. bovis and M. africanum. M. bovis is transmitted by milk from infected cows. This strain of TB is rare, however, because milk is now regularly pasteurized. M. africanum is also rare and occurs primarily in Africa. Those already infected with M. tuberculosis, M. bovis, or M. africanum are most likely to develop active TB within two years of exposure.

TB is spread from one person to another through airborne bacteria. Typically what happens is that a person with TB in the lungs or the throat coughs or sneezes; then, others nearby breathe in the bacteria. When a person breathes in TB bacteria, the bacteria can settle into the lungs and begin to grow.

Who's Most At Risk?

Because TB is only spread through inhalation of infected respiratory particles in the air (see section entitled What Causes It?), you are not likely to contract the infection through other means such as handshakes or sharing of dishes and utensils. Another important fact to remember is that people with TB are most likely to spread it to people with whom they spend the most time—family members, friends, classmates, and coworkers. Those at risk for developing TB include:

• Those who work in the healthcare professions or as embalmers
• Those who were born in or have spent time in a country where TB is common (e.g., most countries in Latin America and the Caribbean, Africa, and Asia, except for Japan)
• Those who live in settings where TB is common (e.g., homeless shelters, migrant farm camps, prisons and jails, and some nursing homes or long-term care facilities)
• Those who are infected with human immunodeficiency virus (HIV)
• Those following therapy that suppresses the immune system
• Those who have no or inadequate access to healthcare

What to Expect at Your Provider's Office

If you are infected with TB, you should expect a healthcare provider to perform an exam and ask about symptoms. He or she will use a stethoscope to pick up unusual breathing sounds, such as bubbling or crackling noises when you inhale after a cough or a hollow blowing sound when you breathe. These may indicate lung-related disease, but your healthcare provider will need to do other tests specifically for TB. A skin test and tests of sputum (mucus and other material coughed up from the lungs) or of fluid or tissue samples may also confirm infection with TB-causing bacteria. Finally, a chest X ray may show signs of TB in the lungs.

Treatment Options

Prevention

• Prevention of TB begins with rapid diagnosis and treatment to avoid spread to noninfected persons.
• Those at risk for developing TB following exposure may be given the medication isoniazid to prevent TB.
• In countries where TB is common, a vaccine called BCG may be administered.

From a public health perspective, the most important way to keep TB from spreading is for infected persons to take their medications exactly as prescribed. If you have TB, keeping all your clinic appointments is essential so that the doctor can check for side effects from the drugs and check the effectiveness of the treatment. If you are sick enough with TB to go to a hospital, you may be put in a special room with air vents that keep the TB bacteria from spreading. You will most likely be prevented from leaving your room and people who come into the room will wear special face masks to protect themselves from TB bacteria and to prevent the spread of TB bacteria to others.

Treatment Plan

If suspicious of TB, healthcare providers may begin treatment before all lab tests return, including prescribing more than one anti-TB drug. Emergency treatment may be necessary if, for example, you are coughing up blood.

Drug Therapies

TB bacteria die very slowly. It takes at least 6 months for the medicine to destroy all of the TB bacteria. If you have TB, you will need to take several different drugs, usually for six to nine months. Treatment lasts longer for those who have HIV or have active TB outside of the lungs. You will be tested first for drug resistance to determine the most effective combination of drugs to prevent the bacteria from becoming resistant to the drugs. The most common drugs used to fight TB are:

• Isoniazid (INH)
• Rifampin
• Pyrazinamide
• Ethambutol
• Streptomycin

Surgical Procedures

Surgery may be needed to repair bone and joint problems caused by TB that has spread to those areas.

Complementary and Alternative Therapies

While it is tempting to think that establishing good nutrition may restore damaged immune function or that dietary supplements may prevent TB infection, effective control of TB depends on appropriate use of medications. Researchers continue, however, to investigate the potential of vitamins and herbs to combat TB.

Nutrition
Patients at risk for vitamin deficiency (malnourished, alcoholics, elderly, pregnant and nursing mothers) or for nerve degeneration (those with diabetes, HIV, or chronic kidney failure) may need vitamin B6. In addition, recent studies have suggested that a diet lacking in certain nutrients may be linked to abnormalities in immune function, resulting in a poor response to TB and to the BCG vaccine, especially among the elderly, children, alcoholics, the homeless, and HIV-infected individuals. These nutrients include:

• Protein
• Zinc
• Vitamin B12
• Vitamin C
• Vitamin D

Animal studies suggest that TB may be more severe in persons with diets rich in omega-3 essential fatty acids compared to those rich in omega-6 essential fatty acids. The omega-3 fatty acids appeared to impair the animals' immune systems, diminishing the ability to kill certain organisms including M. tuberculosis. While it is unclear how this animal study will translate to humans, it may be wise to avoid foods rich in omega-3 fatty acids if you have tuberculosis.

Herbs

• Garlic (Allium sativum)

The antibacterial properties of garlic are fairly well documented. In vitro studies have demonstrated that garlic extract inhibits the growth of many species of bacteria. However, high concentrations of garlic extract were needed to slow down the growth of M. tuberculosis. Such high levels could prove toxic to humans. While further study is needed, a recent animal study indicated that garlic oil (which is a higher concentration than the extract) also inhibited M. tuberculosis, reducing TB lesions. A combination of garlic extract or garlic oil with anti-TB drugs may eventually prove effective against the disease.

Other herbs that may be helpful include:

• Echinacea (Echinacea spp.)
• Tamarisk (Tinospora cordifolia)
• Elecampane (Inula helenium)—used traditionally by native American Indians for lung disorders, including TB
• Barberry (Berberis vulgaris) – used traditionally in Egypt and in modern day Iran for lung infections such as TB
• Sweet coneflower (Rudbeckia subtomentosa)—test tube studies suggest that active components of this herb inhibit the growth of M. tuberculosis

Homeopathy
There have been few studies examining the effectiveness of specific homeopathic remedies. Professional homeopaths, however, may recommend one or more of the following treatments for tuberculosis based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type. In homeopathic terms, a person's constitution is his or her physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

• Arsenicum album —for cough and chest pain, particularly from infectious causes; symptoms worsen at night and are often accompanied by fever, chills, weakness, exhaustion, and restlessness; this remedy is most appropriate for individuals who often feel scared and anxious
• Calcarea carbonica —for chills, drowsiness, perspiration (especially at night), and swollen lymph nodes; this remedy is particularly appropriate for individuals who are susceptible to infection, tend to be stubborn, and crave eggs and cold drinks

Prognosis/Possible Complications

A full course of medication can cure TB in those who do not have a drug-resistant strain. The outcome may be less promising in patients who are elderly, those who have TB that has spread to locations other than the lungs including miliary TB (which spreads through the bloodstream affecting many organ systems), drug-resistant strains of TB, or those with HIV.

Possible complications of TB include:

• Development of a drug-resistant strain
• TB beyond the lungs, frequently associated with HIV
• TB-related meningitis, in children
• Pneumothorax (collapse of a lung due to a buildup of gas between the membranes that surround the lungs)
• Massive coughing up of blood

Following Up

U.S. public health policy requires healthcare providers to report cases of TB and to treat or quarantine all patients. Most patients may remain at home, but all should be kept from any new contacts for at least two weeks after treatment begins. The elderly and those who are acutely ill or have drug-resistant TB should be hospitalized for at least the first few days of treatment.

It is essential to take all TB medication exactly as prescribed in order to cure TB and prevent drug resistance. Any adverse drug reactions should be reported to your healthcare provider right away. Sputum samples are collected and tested monthly. If tests are still positive after three months of treatment, the infection is considered drug resistant and a change in medications is in order.

Special Considerations

• Infants born to mothers with infectious TB should be separated from the mother until she is no longer contagious. The infant should then be tested for TB at four to six weeks and three to four months.
• Women can be treated for TB during pregnancy and while breast-feeding but should avoid streptomycin and pyrazinamide.

Treating TB does require common sense in minimizing the spread of the disease to yourself and to others as well as communication and cooperation with your healthcare provider. Since the effective treatment of TB depends on the use of multiple antibiotic drugs for an extended period of time, it is essential that you consult with your healthcare provider before pursuing any complementary or alternative therapies, including taking herbs and vitamin supplements.

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