Tuberculosis? Didn't that disappear in the last century?

Tuberculosis, commonly known as TB, is one of the oldest known infectious diseases, having been found in Egyptian mummies from 3000 BC.

In 17th and 18th century Europe it was known as “consumption,” and was commonly depicted in literature and opera. Marguerite, the heroine of the novel The Lady of the Camelias and the opera La Traviata dies of TB, as do Fantine in Les Misérables and Mimi in La Boheme.

Only in 1882 did Robert Koch discover Mycobacterium tuberculosis, the bacterium that causes TB.

While TB was widespread in the US until well into the early 20th century, cases are now much less common. TB is very much a disease of poverty and crowding, and economically advanced countries see much less of it.

In the last few years, cases have been rising. There were about 8200 reported cases of TB in the US in 2022, 9600 in 2023 and 10,300 in 2024. Most of these occurred in immigrants, and most represented reactivation of old infections when the person’s immunity dropped.

Worldwide it is a different story. TB is the most common infectious cause of death in the world. In 2023, an estimated 11 million people fell ill with TB and 1.3 million died. TB is very common in southern Africa and central Asia and is a major health problem in India and China.

The best preventive measure, as with most infectious diseases, is vaccination. BCG vaccine (Bacillus Calmette-Guerin) was developed in 1921 and is particularly helpful for children, preventing the worst forms of TB. It is less effective in preventing pulmonary (lung) infection, which is by far the most common form of TB.

Once given universally, BCG vaccine is now routinely used only in Ireland and Portugal among affluent countries and is not commercially available in the US or most western countries. It is routinely given to newborns in much of Asia, southern Africa and South America.

You can still get TB, a highly transmissible illness from someone who has it in their lungs and is coughing. While you are unlikely to catch it in normal tourist sites even in high-incidence countries, it does happen.

Fortunately, active TB is usually easy to diagnose from a standard chest X-ray. Treatment is usually effective, though drug-resistant TB is not rare.

So, forgotten but not gone. As the cuts in USAID funds for disease prevention take hold, there will be a lot more TB, and some of it will hit our shores.


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Is your doctor gaslighting you?

The term "gaslighting" originates from a 1938 play and later movie which depicted a husband who manipulates his wife by dimming their gaslights and then denying that the lights have changed, making her doubt her own perception and sanity. The term has since become a psychological term for a form of emotional abuse where one person manipulates another into questioning their own reality.

In the patient safety movement, we hear the term used over and over by patients who feel their concerns are not being taken seriously by their doctors.

Many diagnoses are easy to make and verify, and that satisfies both the patient, who has an explanation for their symptoms, and the doctor, who can suggest treatment and move on to the next patient. If you have visible bleeding or an abnormal ECG or blood test, the disease can be quickly diagnosed.

Many diseases are not that easy to diagnose. The symptoms may be vague and common to many illnesses, and there may be no reliable tests to confirm or refute the diagnosis. This is particularly true for auto-immune disorders. Many such diseases are commoner in women than men, and women are much more likely to report that their doctor tried to say the symptoms were “all in their head.”

Commonly dismissed conditions include post-traumatic stress disorder (PTSD), long Covid and fibromyalgia.

A classic disease that can present in a wide variety of ways and which has no reliable blood or imaging test is endometriosis. Cells that normally line the uterus implant anywhere in the abdomen and cause recurrent pain. It has been found that it takes an average of 8.5 years between a woman first describing her symptoms and a diagnosis being made.

The way out of this dilemma is for both doctors and patients to become comfortable with uncertainty.

The worst thing a doctor can say when confronted with symptoms that have no obvious explanation is “It is all in your head. You are anxious.”

What the doctor should say is “I have no immediate explanation for your symptoms, but I believe what you are telling me, and we will work together to find out what is going on.”

This process may simply require some time to pass. A diagnosis often becomes more obvious over time. Many painful conditions are self-limited and will resolve over weeks.

Diagnosis may require a second (or third) opinion. It may require more detailed imaging or invasive testing that are not appropriate at first presentation, but which are justified as the symptoms evolve.

If you have a doctor who will work with you in this way, hold on to them.

If your doctor “gaslights” you, find another doctor!


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West Nile Virus - what it is, how to avoid it

The West Nile virus (WNV) was first identified in 1937 in Uganda, and it remained confined to East Africa for many decades. With travel and climate change, it has dramatically expanded its range since the late 1990’s, and is now found in every U.S. state, southern Canada and southern and eastern Europe.

Birds are the main host for WNV, and the virus is spread by mosquitoes, both bird to bird and bird to human. Humans are infected when a mosquito feeds on an infected bird and then bites a person. There is no direct person-to-person spread.

Fortunately, 80% of people infected have no symptoms, but about 20% develop a fever and a variety of other symptoms. Common symptoms are headache, pain behind the eyes, weakness, muscle aches, rash, nausea, vomiting and diarrhea. These come on anywhere from 2 days to 2 weeks after being bitten, so you may well not remember the bite. Symptoms may last for weeks.

A small percentage (less than 1%) of those with WNV symptoms can have much more serious illness, with the virus infecting the brain (encephalitis) and/or the tissues around the spine (meningitis).

There is no treatment for West Nile illness. For those with mild or moderate symptoms, acetaminophen, fluids and rest are advised. If you are among the severely infected, hospitalization is needed, and one in ten with neurologic disease dies, while many more are left with persistent deficits.

Since there is no treatment, and to date no vaccine, preventing mosquito bites is our best defense.

During mosquito season, avoid being outdoors at dawn and dusk or after a rainfall, when the insects are most active. Wear long-sleeved clothing. Use effective mosquito repellants, preferably those with 20-30% DEET. Do not allow standing water on your property to minimize mosquito breeding sites. When it is offered, request that local mosquito-control agencies spray your property.

Avoiding mosquito bites will also reduce the risk of many other mosquito-borne diseases. These vary with your geographic region but include Eastern Equine Encephalitis in Mass, Florida and Michigan; Zika, dengue fever and chikungunya in the southern U.S., and malaria in many parts of Africa, Asia and Central and South America.

“Better DEET than dead.”


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Blood tests for cancer screening: should I get one?

You may have seen print or television ads promoting the Galleri blood test for “early cancer detection.” Neither this test nor any others are covered by Medicare or commercial insurance, but you can have it if ordered by your doctor and you are willing to pay $949 out of pocket.

Assuming you can afford it, is it worth it?

It is considered self-evident that detecting cancer early is better than finding it late, and routine colonoscopy for the detection of early cancer or pre-cancerous polyps does prevent colon cancer deaths. Screening smokers for lung cancer with low-dose chest CT scans has also been shown to reduce the death rate from lung cancer. While somewhat controversial, there is evidence that routine mammograms reduce breast cancer deaths.

This leaves many cancers for which there is no accepted screening tool. Also, not all eligible people are able or willing to have the tests mentioned. Enter the “liquid biopsy,” a single blood test that promises to detect many cancers.

These tests work by detecting minute amounts of tumor DNA or abnormal proteins secreted by cancers.

There are many problems with these tests.

First, while they are pretty good (90%) at detecting advanced cancer, which has already spread, they are much less effective (15%) at detecting early localized cancers, the kind where early detection and surgery is expected to be life-saving.

Secondly, they have a high number of “false positives:” an abnormal test but no detectable cancer. In two large studies, enrolling over 16,000 people, 600 people had positive tests. The large majority had no cancer and only 14 had early-stage solid tumors that were treated. Most of the positive tests required extensive imaging and invasive biopsies to be sure there was no cancer.

To date, there has not been any evidence that screening with a blood test saves lives.

Bottom line: have your colonoscopy. Have your Pap and mammogram. If you are middle-aged and have smoked, have a screening chest CT.

I am sure that more precise and actionable tests are on the horizon. For the time being, do not spend your money on a blood test that is unlikely to impact your survival and that may lead to uncomfortable and possibly dangerous testing.




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