1 00:00:00,000 --> 00:00:12,800 Thanks for joining us again at the Canadian Breakpoint, a Canadian infectious diseases 2 00:00:12,800 --> 00:00:17,080 podcast by Canadian infectious diseases physicians. 3 00:00:17,080 --> 00:00:22,200 I'm Summer Stewart, here with Dr. Rupeena Purewal, pediatric infectious diseases specialist 4 00:00:22,200 --> 00:00:23,760 from Saskatoon. 5 00:00:23,760 --> 00:00:29,500 In this episode, we welcome Dr. Amalia Brindamore, pediatrician with the Saskatchewan TB Prevention 6 00:00:29,500 --> 00:00:33,040 and Control Program to review complicated TB cases. 7 00:00:33,040 --> 00:00:34,040 Dr. Purewal. 8 00:00:34,040 --> 00:00:39,280 All right, welcome to another episode of our podcast the Canadian Breakpoint. 9 00:00:39,280 --> 00:00:45,320 Today we have a very special guest and actually a close friend of mine, Dr. Brindamore, who 10 00:00:45,320 --> 00:00:49,640 will be talking about complicated tuberculosis cases. 11 00:00:49,640 --> 00:00:54,800 So just an introduction, Dr. Amalia Brindamore is a general pediatrician with a special interest 12 00:00:54,800 --> 00:00:56,860 in global health. 13 00:00:56,860 --> 00:01:02,480 She works as a tuberculosis consultant with the Saskatchewan Tuberculosis Prevention and 14 00:01:02,480 --> 00:01:08,200 Control Program, where she supports TB care for children and adults in several areas of 15 00:01:08,200 --> 00:01:10,120 the province. 16 00:01:10,120 --> 00:01:16,000 She co founded Saskatoon's Refugee Engagement and Community Health, which is known as REACH 17 00:01:16,000 --> 00:01:21,280 Clinic, where she cares for refugee children with complex needs. 18 00:01:21,280 --> 00:01:26,480 She also provides outreach pediatric clinic care to the northern Saskatchewan communities 19 00:01:26,480 --> 00:01:30,440 of Islay Cross, Lelosh and Stony Rapids. 20 00:01:30,440 --> 00:01:32,000 So welcome Dr. Brindamore. 21 00:01:32,000 --> 00:01:34,560 Hello, thank you so much for inviting me. 22 00:01:34,560 --> 00:01:36,560 Such an honor to be here. 23 00:01:36,560 --> 00:01:44,040 No, it's an honor for us because we have somebody who is an expert in TB and a lot of provinces 24 00:01:44,040 --> 00:01:46,040 are seeing complicated cases. 25 00:01:46,040 --> 00:01:51,760 And so we've had a lot of requests to kind of talk about management, how do we manage 26 00:01:51,760 --> 00:01:57,640 these patients and hearing it from an expert is a pleasure for us. 27 00:01:57,640 --> 00:02:02,920 And actually, it's a great follow up episode because we just had Dr. De Willow on who actually 28 00:02:02,920 --> 00:02:10,120 helped edit some of the Canadian TB guidelines that were updated in March 2022. 29 00:02:10,120 --> 00:02:14,000 So a lot of our listeners had a chance to review these updates. 30 00:02:14,000 --> 00:02:16,320 And so this is a great follow up episode. 31 00:02:16,320 --> 00:02:18,880 So super excited to have you on board. 32 00:02:18,880 --> 00:02:19,880 Thank you. 33 00:02:19,880 --> 00:02:25,600 I think the first episode I listened to it and it's a hard act to follow. 34 00:02:25,600 --> 00:02:27,200 All right. 35 00:02:27,200 --> 00:02:33,560 So I think in terms of compared to our different our podcast episodes previously, this will 36 00:02:33,560 --> 00:02:36,280 be a bit of a different approach. 37 00:02:36,280 --> 00:02:42,280 So we'll be talking about a few cases, complicated cases where we'll walk through the overview 38 00:02:42,280 --> 00:02:48,960 and the details of the case approach to managing how did the patient overall do and really 39 00:02:48,960 --> 00:02:55,000 for us clinicians and other health care providers, how would we have managed this differently 40 00:02:55,000 --> 00:03:00,960 and what resources do we have and keeping in mind that the cases that you're seeing 41 00:03:00,960 --> 00:03:07,080 are in Saskatchewan, but definitely applicable to the rest of Canada and pretty much North 42 00:03:07,080 --> 00:03:08,840 America. 43 00:03:08,840 --> 00:03:11,520 So we have listeners from across the globe. 44 00:03:11,520 --> 00:03:15,480 And so we're kind of excited to hear some of these cases. 45 00:03:15,480 --> 00:03:20,920 And I would like to give a disclaimer that this podcast is for informational purposes 46 00:03:20,920 --> 00:03:26,680 only and it does not replace an infectious disease or TB expert consult. 47 00:03:26,680 --> 00:03:27,680 All right. 48 00:03:27,680 --> 00:03:32,600 So with further ado, why don't we start and I'll hand over the microphone to you, Dr. 49 00:03:32,600 --> 00:03:33,600 Brynner-Mor. 50 00:03:33,600 --> 00:03:34,600 Thank you so much. 51 00:03:34,600 --> 00:03:37,680 So I have three cases to talk about. 52 00:03:37,680 --> 00:03:45,440 And the way I chose them is I chose cases that were either complex in terms of management 53 00:03:45,440 --> 00:03:55,520 or complex in terms of challenging or challenges in accessing care or atypical presentations. 54 00:03:55,520 --> 00:03:58,800 And then we can unpack them and go through them. 55 00:03:58,800 --> 00:04:05,840 And I also wanted to illustrate what kind of outcome we're trying to prevent when we 56 00:04:05,840 --> 00:04:13,440 care for these kids and why tuberculosis in kids is such urgent to look after, important 57 00:04:13,440 --> 00:04:19,640 to think about and be really persistent in finding the cases and following up. 58 00:04:19,640 --> 00:04:25,380 So the first case is really a tragic story. 59 00:04:25,380 --> 00:04:30,520 But what I wanted to outline was, again, what we were trying to prevent when we deal with 60 00:04:30,520 --> 00:04:31,520 pediatric TB. 61 00:04:31,520 --> 00:04:40,440 And so that's why I chose to talk about this case first to illustrate how severe and horrible 62 00:04:40,440 --> 00:04:42,940 these cases can be. 63 00:04:42,940 --> 00:04:46,840 And almost 100% of the time, preventable. 64 00:04:46,840 --> 00:04:49,600 So the details have been changed. 65 00:04:49,600 --> 00:04:54,120 I changed the name of the communities and the name of the patients, et cetera, changed 66 00:04:54,120 --> 00:04:57,880 a few details of their history so that they're not recognizable. 67 00:04:57,880 --> 00:05:03,840 But this case is about four-month-old Victor and his sister Carla. 68 00:05:03,840 --> 00:05:09,280 And Victor presented to a peripheral emergency department, so not in a big city, but not 69 00:05:09,280 --> 00:05:16,200 in a small town either, with a two-week history of cough, wheeze, and intermittent subjective 70 00:05:16,200 --> 00:05:20,400 fevers, as we say in peeps, so tactile fevers. 71 00:05:20,400 --> 00:05:24,360 He was seen by the eMERGE doc who did a chest x-ray because he thought it was a little bit 72 00:05:24,360 --> 00:05:27,200 prolonged and odd and he's little. 73 00:05:27,200 --> 00:05:34,960 And so that chest x-ray shows diffuse patchy consolidation, worse than a ripe upper lobe, 74 00:05:34,960 --> 00:05:40,880 and then this huge lesion that's described as a mass-like lesion, needing follow-up, 75 00:05:40,880 --> 00:05:46,680 most likely due to infection, suggesting repeated chest x-ray in a few weeks or CT, et cetera. 76 00:05:46,680 --> 00:05:48,520 So they consult peeds. 77 00:05:48,520 --> 00:05:53,040 He's admitted on the ward, in the general pediatric ward for pneumonia. 78 00:05:53,040 --> 00:05:55,480 He started on IV antibiotics. 79 00:05:55,480 --> 00:05:57,520 And truthfully, his baby was on room air. 80 00:05:57,520 --> 00:05:59,720 He was systemically super well. 81 00:05:59,720 --> 00:06:01,680 He didn't really have any work of breathing. 82 00:06:01,680 --> 00:06:09,000 He didn't really have any findings on physical exam other than minimal intermittent wheeze. 83 00:06:09,000 --> 00:06:12,480 And so there was no rush or any acuity to that. 84 00:06:12,480 --> 00:06:14,600 And so they do a CT scan the next day. 85 00:06:14,600 --> 00:06:23,760 And that CT shows large necrotic, peritracheal, metastinal, and right hyaluradenopathies that 86 00:06:23,760 --> 00:06:26,980 are obstructing the right mainstream bronchus. 87 00:06:26,980 --> 00:06:31,760 And he has extensive consolidation in the right upper and right middle lobes. 88 00:06:31,760 --> 00:06:38,020 And the report says, most likely malignancy, query TB. 89 00:06:38,020 --> 00:06:42,880 And so after that CT result, which is often what we see in cases of TB is like, well, 90 00:06:42,880 --> 00:06:47,240 I can't rule out infection, but most likely malignancy. 91 00:06:47,240 --> 00:06:54,200 But a pediatrician looks at that, goes back to the family, and asks a few more questions. 92 00:06:54,200 --> 00:07:02,040 And what they find out is that the parents are asking, do you think this could be due 93 00:07:02,040 --> 00:07:05,520 to the illness that his older sister had? 94 00:07:05,520 --> 00:07:11,600 And the older sister died two weeks ago from an unknown cause. 95 00:07:11,600 --> 00:07:18,840 She just got found unresponsive at home and brought to the hospital where she died in 96 00:07:18,840 --> 00:07:23,360 the hospital before kind of anything was done. 97 00:07:23,360 --> 00:07:30,400 Other than a chest X-ray and a CT, and that chest X-ray and that CT showed extensive cavitations 98 00:07:30,400 --> 00:07:34,360 and twin bud, twin bud opacities. 99 00:07:34,360 --> 00:07:39,200 And there were some thoughts that perhaps her pulmonary artery was eroded and that led 100 00:07:39,200 --> 00:07:42,120 to a subsequent hemorrhage, and that's how she died. 101 00:07:42,120 --> 00:07:43,560 There was no samples that were taken. 102 00:07:43,560 --> 00:07:49,600 And the family wasn't really kind of provided any explanation. 103 00:07:49,600 --> 00:07:54,600 And so finding this out, the pediatrician in the periphery is very worried, calls the 104 00:07:54,600 --> 00:07:59,280 TB program in Saskatoon and say, have you heard about this baby? 105 00:07:59,280 --> 00:08:01,040 Like, is he on your radar? 106 00:08:01,040 --> 00:08:04,440 Have you treated this family or this sister before? 107 00:08:04,440 --> 00:08:06,560 And then of course, we've never heard about them. 108 00:08:06,560 --> 00:08:07,560 We've never heard about the sister. 109 00:08:07,560 --> 00:08:11,080 We've never heard about the baby. 110 00:08:11,080 --> 00:08:15,740 But that story was so concerning that further investigations on Victor were done. 111 00:08:15,740 --> 00:08:22,680 And so of course, not of course, this is actually atypical, but we found bacteriological confirmation 112 00:08:22,680 --> 00:08:23,680 for Victor. 113 00:08:23,680 --> 00:08:30,360 So they did gastric washing and the gene experts for TB was positive and the culture was positive 114 00:08:30,360 --> 00:08:31,360 subsequently. 115 00:08:31,360 --> 00:08:36,440 He also had an Aigra that was positive and a Mentu that was positive. 116 00:08:36,440 --> 00:08:38,680 And it's rare that we get all of that. 117 00:08:38,680 --> 00:08:42,160 It's rare that we get bacteriological confirmation. 118 00:08:42,160 --> 00:08:50,360 Often the Aigra and the Mentu often are negative and if you don't have the epi link, it's often 119 00:08:50,360 --> 00:08:51,920 very difficult to make the diagnosis. 120 00:08:51,920 --> 00:08:55,320 So we were lucky on that case. 121 00:08:55,320 --> 00:09:02,440 So he was started on regular pulmonary TB treatment with the RIPE regimen. 122 00:09:02,440 --> 00:09:03,440 And then he did quite well. 123 00:09:03,440 --> 00:09:09,080 He was followed by the TB program, had full recovery and his chest x-ray post-treatment 124 00:09:09,080 --> 00:09:11,840 looked completely normal. 125 00:09:11,840 --> 00:09:15,480 And he's done his treatment for a few months and he's done really well. 126 00:09:15,480 --> 00:09:19,520 But then the question is, where did he catch this? 127 00:09:19,520 --> 00:09:21,640 Where is this TB coming from? 128 00:09:21,640 --> 00:09:25,380 So of course, the sister's case was suspicious, but we were never able to obtain samples. 129 00:09:25,380 --> 00:09:30,000 We tried to do post-mortem, but that wasn't successful. 130 00:09:30,000 --> 00:09:36,080 The TB nurses initiated a source-trace investigation for the baby and they also did at the same 131 00:09:36,080 --> 00:09:42,160 time contact tracing investigation for his sister that they considered as an infectious 132 00:09:42,160 --> 00:09:45,080 active, but that wasn't completely confirmed. 133 00:09:45,080 --> 00:09:50,480 And so through these investigations, they found a link to the kid's grandma that they 134 00:09:50,480 --> 00:09:53,160 were visiting often. 135 00:09:53,160 --> 00:09:58,560 And his grandma had family ties with several communities up north. 136 00:09:58,560 --> 00:10:05,720 And what she was doing is that she was supporting several people who had challenges with housing 137 00:10:05,720 --> 00:10:13,200 in her community, including one specific person who appeared to have been coughing for a very 138 00:10:13,200 --> 00:10:18,880 long time that she identified as part of the contact tracing. 139 00:10:18,880 --> 00:10:25,040 This individual had no phone, no address, was very hard to find. 140 00:10:25,040 --> 00:10:27,720 And the TB nurses really persisted for several weeks. 141 00:10:27,720 --> 00:10:32,720 They sent letter to several family members in different communities, to his uncle, his 142 00:10:32,720 --> 00:10:39,640 grandma, his siblings, they phone everybody who had a phone and were really persistent, 143 00:10:39,640 --> 00:10:43,400 but they were never able to find him. 144 00:10:43,400 --> 00:10:51,400 But eventually some weeks passed and then this person shows up at the TB program office 145 00:10:51,400 --> 00:10:56,640 because he got all of the letters, kept them. 146 00:10:56,640 --> 00:11:01,560 And then when he started coughing up blood, he said, maybe I have TB. 147 00:11:01,560 --> 00:11:05,760 I'm going to go to the address that's on those letters and showed up. 148 00:11:05,760 --> 00:11:12,800 And through him, who of course he had TB, they were able to do the complete genogram 149 00:11:12,800 --> 00:11:19,360 that linked this person and these two kids to an area of the province where an outbreak 150 00:11:19,360 --> 00:11:21,960 was eventually called a few weeks after. 151 00:11:21,960 --> 00:11:29,080 And so everything kind of fell together and made sense, but it took several weeks of detective 152 00:11:29,080 --> 00:11:34,840 work for the TB nurses to find that. 153 00:11:34,840 --> 00:11:39,360 And in the end, so this guy is also on treatment, doing well and recovered. 154 00:11:39,360 --> 00:11:40,360 Yeah. 155 00:11:40,360 --> 00:11:45,320 So quite challenging in terms of like, I think, I mean, one of the challenges that I would 156 00:11:45,320 --> 00:11:50,920 face in that case is to never identify difficulty identifying the index case, right? 157 00:11:50,920 --> 00:11:51,920 Exactly. 158 00:11:51,920 --> 00:11:58,280 And like contact tracing, especially when you don't, especially in a province like Saskatchewan, 159 00:11:58,280 --> 00:12:03,400 where sometimes the address that we have provided for some of the patients isn't, you know, 160 00:12:03,400 --> 00:12:05,160 their permanent address. 161 00:12:05,160 --> 00:12:07,160 And so there's a lot of moving around. 162 00:12:07,160 --> 00:12:11,200 And I'm sure like some learn Manitoba, they must be experiencing that as well. 163 00:12:11,200 --> 00:12:14,440 So that is quite challenging for sure. 164 00:12:14,440 --> 00:12:18,680 And so it's tedious detective work. 165 00:12:18,680 --> 00:12:19,680 Definitely. 166 00:12:19,680 --> 00:12:25,240 And, but it's really the contact tracing and the source investigations that will make everything 167 00:12:25,240 --> 00:12:26,240 make sense. 168 00:12:26,240 --> 00:12:33,680 So I often look at these mapping and the genograms and the family trees and it comports us in 169 00:12:33,680 --> 00:12:39,720 our diagnoses, especially in pediatrics where it's so rare to get good bacteriological confirmation. 170 00:12:39,720 --> 00:12:45,980 When the links and the epilinks make sense, it makes me feel better about not treating 171 00:12:45,980 --> 00:12:51,960 them for nothing or over treating people when really the link is there. 172 00:12:51,960 --> 00:12:54,600 Sometimes it takes a long time to find it. 173 00:12:54,600 --> 00:12:55,600 Yeah. 174 00:12:55,600 --> 00:12:56,600 Yeah, that's fair. 175 00:12:56,600 --> 00:12:57,600 Yeah. 176 00:12:57,600 --> 00:13:02,560 So how would you, is there like, I guess, locally in Saskatchewan, public health would 177 00:13:02,560 --> 00:13:08,440 be able to help clinicians if they were in a situation like that, where they need to 178 00:13:08,440 --> 00:13:13,520 get some help with contact tracing or is it mainly like TB control? 179 00:13:13,520 --> 00:13:14,520 It depends. 180 00:13:14,520 --> 00:13:15,520 It varies province by province. 181 00:13:15,520 --> 00:13:19,200 I know that in some provinces, it's public health that does that. 182 00:13:19,200 --> 00:13:25,920 In Saskatchewan, it's the TB program specifically that has TB nurse clinicians that are looking 183 00:13:25,920 --> 00:13:27,200 after this contact tracing. 184 00:13:27,200 --> 00:13:29,360 But there's lots of partnership going on, right? 185 00:13:29,360 --> 00:13:36,280 We do talk to public health, talk to community health nurses in different communities. 186 00:13:36,280 --> 00:13:40,220 And it takes a lot of discussion with lots of people to help with that. 187 00:13:40,220 --> 00:13:44,600 But that would be in Saskatchewan, particularly the TB program that would be responsible for 188 00:13:44,600 --> 00:13:45,600 that. 189 00:13:45,600 --> 00:13:46,600 Okay. 190 00:13:46,600 --> 00:13:47,600 Right. 191 00:13:47,600 --> 00:13:48,600 Yeah. 192 00:13:48,600 --> 00:13:52,000 And what's odd about this, the importance of the genogram and the importance of the 193 00:13:52,000 --> 00:13:58,040 contact tracing is that through that, it's obvious to say for people doing this work 194 00:13:58,040 --> 00:14:04,320 every day, but how you identify high risk contacts and prevent these outcomes from occurring 195 00:14:04,320 --> 00:14:05,320 in more babies. 196 00:14:05,320 --> 00:14:11,040 And so, for example, through this contact trace investigations, we were able to identify 197 00:14:11,040 --> 00:14:17,800 several active adults who were in contact with several other kids and dozens of kids 198 00:14:17,800 --> 00:14:19,880 needed to be profiled as a result. 199 00:14:19,880 --> 00:14:31,280 We had at least five or six that I can think of active cases that were unearthed as a 200 00:14:31,280 --> 00:14:32,600 contact tracing. 201 00:14:32,600 --> 00:14:33,600 Wow. 202 00:14:33,600 --> 00:14:34,600 Yeah. 203 00:14:34,600 --> 00:14:39,120 So I guess, I mean, again, like you said, the importance of going back and finding 204 00:14:39,120 --> 00:14:45,000 index stations, contact tracing, and then really preventing such severe disease. 205 00:14:45,000 --> 00:14:47,000 I mean, that is the presentation. 206 00:14:47,000 --> 00:14:52,080 I mean, it's already very tragic to know that a child lost their life most likely due to 207 00:14:52,080 --> 00:14:53,080 that. 208 00:14:53,080 --> 00:15:00,600 And then in kind of looking at even Victor's case here, that is a very severe presentation 209 00:15:00,600 --> 00:15:04,880 where they're presenting with such significant CT findings. 210 00:15:04,880 --> 00:15:11,480 And we, you know, that's actually disheartening to know that all of that could have been prevented. 211 00:15:11,480 --> 00:15:12,480 Absolutely. 212 00:15:12,480 --> 00:15:13,480 Yeah. 213 00:15:13,480 --> 00:15:18,480 And then we have the classic presentation of the adenopathy is causing tracheal compression 214 00:15:18,480 --> 00:15:20,320 and a fairly rapid progression, right? 215 00:15:20,320 --> 00:15:25,240 He was only four months and had had symptoms for only a couple of weeks. 216 00:15:25,240 --> 00:15:31,320 And that's a classic presentation of a less than one year old child who really with TB 217 00:15:31,320 --> 00:15:36,200 doesn't have the classic symptoms, might show up like a viral infection that doesn't go 218 00:15:36,200 --> 00:15:41,720 away and doesn't have a lot of findings on physical exam despite potentially very severe 219 00:15:41,720 --> 00:15:42,720 disease. 220 00:15:42,720 --> 00:15:49,680 And same thing for his sister where, you know, she had a little cough for two years and she 221 00:15:49,680 --> 00:15:50,840 didn't see care. 222 00:15:50,840 --> 00:15:55,000 So she wasn't identified early enough. 223 00:15:55,000 --> 00:16:00,120 There was this history where maybe she went to a walking clinic a week prior to the events 224 00:16:00,120 --> 00:16:01,120 treated like asthma. 225 00:16:01,120 --> 00:16:07,360 There was no imaging that was done, but that's not necessarily atypical for how we would 226 00:16:07,360 --> 00:16:08,680 manage other children. 227 00:16:08,680 --> 00:16:13,040 So we really have to have TB, you know, at the top of my mind all the time to find these 228 00:16:13,040 --> 00:16:14,040 cases. 229 00:16:14,040 --> 00:16:15,040 Yeah. 230 00:16:15,040 --> 00:16:19,360 And I think so kind of like a couple of like, I guess, key points that I would take back, 231 00:16:19,360 --> 00:16:24,160 you know, take away from this case would be how important is to contact trace, inform 232 00:16:24,160 --> 00:16:30,120 others if you're like seeing any child that might have symptoms that are consistent with 233 00:16:30,120 --> 00:16:31,120 that. 234 00:16:31,120 --> 00:16:36,240 And then having that high suspicion of TB in the back, especially if you have TB in 235 00:16:36,240 --> 00:16:41,640 your communities and it's endemic in certain communities and really thinking like a chronic 236 00:16:41,640 --> 00:16:48,360 cough and child that's not improving should probably warrant us to think about tuberculosis. 237 00:16:48,360 --> 00:16:54,160 So I think for some of our first, you know, first line defense positions out there who 238 00:16:54,160 --> 00:16:56,680 sometimes don't know anything about these patients, right? 239 00:16:56,680 --> 00:17:00,840 Like it's very difficult for them because for instance, like walk in clinic physicians, 240 00:17:00,840 --> 00:17:01,840 right? 241 00:17:01,840 --> 00:17:04,800 They don't have a background history of these patients. 242 00:17:04,800 --> 00:17:07,240 They don't have their family history. 243 00:17:07,240 --> 00:17:11,320 And so, you know, managing patients, but just keeping that on high alert, especially in 244 00:17:11,320 --> 00:17:15,800 a province like Saskatchewan where we do see a lot of endemic TB. 245 00:17:15,800 --> 00:17:20,360 So those are some of the things that I would take back and bring into my practice for sure. 246 00:17:20,360 --> 00:17:26,640 Is there any other key points that you think we should address maybe for some of our listeners 247 00:17:26,640 --> 00:17:27,640 for this case? 248 00:17:27,640 --> 00:17:28,640 Not for this case. 249 00:17:28,640 --> 00:17:32,960 And I think we can go to other key points a little bit later. 250 00:17:32,960 --> 00:17:36,240 I almost feel like these key points for TB are so cliche, right? 251 00:17:36,240 --> 00:17:42,360 Like it could always be TB, but really, but really that's what it is. 252 00:17:42,360 --> 00:17:44,200 Yeah, I know. 253 00:17:44,200 --> 00:17:51,840 And to be honest, I think it's like having knowing what's common in your areas of practice, 254 00:17:51,840 --> 00:17:54,160 I think is really important. 255 00:17:54,160 --> 00:17:59,000 And it's always the same, you know, if it looks like it, it probably is TB. 256 00:17:59,000 --> 00:18:03,280 And so we should always keep that on our differentials. 257 00:18:03,280 --> 00:18:07,760 I think sometimes it's just good to familiarize ourselves and remind ourselves that it's still 258 00:18:07,760 --> 00:18:08,760 on the differential. 259 00:18:08,760 --> 00:18:09,760 Absolutely. 260 00:18:09,760 --> 00:18:10,760 Yeah. 261 00:18:10,760 --> 00:18:11,760 All right. 262 00:18:11,760 --> 00:18:14,000 Do you want to walk us to the second case then? 263 00:18:14,000 --> 00:18:15,000 Yes. 264 00:18:15,000 --> 00:18:22,240 So this second case is not necessarily a complex case because of her presentation, but it was 265 00:18:22,240 --> 00:18:28,040 really the treatment that was challenging for her and for everyone around her. 266 00:18:28,040 --> 00:18:31,740 So this is four-year-old Claire. 267 00:18:31,740 --> 00:18:38,640 And her case not only talks about barriers to accessing care, but also the stigma surrounding 268 00:18:38,640 --> 00:18:44,280 TB that is very, very strong everywhere in the province. 269 00:18:44,280 --> 00:18:51,360 So anyways, Claire is four and she was identified through contact tracing again of a smear positive 270 00:18:51,360 --> 00:18:52,720 pulmonary TB case. 271 00:18:52,720 --> 00:18:55,960 So she was a high risk household contact. 272 00:18:55,960 --> 00:18:58,800 And because she's less than five years, it's urgent. 273 00:18:58,800 --> 00:19:04,600 So we tend to see these kids or we want to see these kids quicker and we do more investigation 274 00:19:04,600 --> 00:19:10,480 and have a lower threshold to see them faster than others. 275 00:19:10,480 --> 00:19:16,520 So as for the guidelines, we needed a skin test right away as soon as she's identified 276 00:19:16,520 --> 00:19:23,280 with a MENTU and then a repeated MENTU if that one is negative at eight weeks post-exposure. 277 00:19:23,280 --> 00:19:27,280 And then all kids in that time, we do a chest x-ray in addition to symptom inquiry and a 278 00:19:27,280 --> 00:19:29,680 physical exam, et cetera. 279 00:19:29,680 --> 00:19:37,120 But just that was very complicated because the family struggle with unstable housing. 280 00:19:37,120 --> 00:19:39,840 They didn't have a phone. 281 00:19:39,840 --> 00:19:41,880 And so they were very difficult to find. 282 00:19:41,880 --> 00:19:48,880 We again called everybody we could, send letters to the clinic in the community where they 283 00:19:48,880 --> 00:19:49,880 lived. 284 00:19:49,880 --> 00:19:52,800 We contacted family members. 285 00:19:52,800 --> 00:19:56,040 And on top of all of that, it was in the middle of COVID. 286 00:19:56,040 --> 00:19:58,080 So that was the first year of COVID. 287 00:19:58,080 --> 00:20:04,080 So all of our clinics were canceled and we were only doing telehealth clinics, which 288 00:20:04,080 --> 00:20:09,680 really isn't ideal to go look for people in their community. 289 00:20:09,680 --> 00:20:17,120 And the TB workers who are really miracle workers in the community where she lives, 290 00:20:17,120 --> 00:20:20,800 tried to go to their house multiple times, but people would not answer the door, would 291 00:20:20,800 --> 00:20:23,160 not want to talk to them or everyone was sleeping. 292 00:20:23,160 --> 00:20:29,360 Anyways, it was a hard time and it took many, many, many weeks before we could talk to them. 293 00:20:29,360 --> 00:20:34,280 Then the next barrier was how do you do a chest x-ray? 294 00:20:34,280 --> 00:20:40,920 You don't have a chest x-ray machine in that community and they need to drive or find some 295 00:20:40,920 --> 00:20:46,780 transport to go in another community an hour and a half away to go do a chest x-ray. 296 00:20:46,780 --> 00:20:51,720 This family has several children, they work. 297 00:20:51,720 --> 00:20:53,280 It's very complicated to do that. 298 00:20:53,280 --> 00:20:59,440 So we booked her six times for a chest x-ray and she never went to do the chest x-ray. 299 00:20:59,440 --> 00:21:02,600 She did have a skin test, but she never came back to have it read. 300 00:21:02,600 --> 00:21:06,380 So we can't piece out our information that we need. 301 00:21:06,380 --> 00:21:10,040 So eventually we succeed in talking to them. 302 00:21:10,040 --> 00:21:14,520 And in talking to the family, we decided, would it be easier if we brought you to the 303 00:21:14,520 --> 00:21:21,680 big city to see us and we could do everything at the same time, examine you, we would see 304 00:21:21,680 --> 00:21:24,760 all the family members at the same time. 305 00:21:24,760 --> 00:21:28,780 And to me that sounded very overwhelming and I didn't think they would do that, but somehow 306 00:21:28,780 --> 00:21:31,640 that was their preferred way of doing things. 307 00:21:31,640 --> 00:21:35,160 They organized for them to come and they come. 308 00:21:35,160 --> 00:21:37,800 And so we're able to do the chest x-ray. 309 00:21:37,800 --> 00:21:39,160 We do an eye graph. 310 00:21:39,160 --> 00:21:46,120 We examine the child and the sister who was also with sex at that time and was also a 311 00:21:46,120 --> 00:21:47,120 con. 312 00:21:47,120 --> 00:21:52,040 And so we see them in our little TV room in the hospital, like in the old part of the 313 00:21:52,040 --> 00:21:57,880 hospital where there's no window and there's not really an examination bed. 314 00:21:57,880 --> 00:22:03,280 And so Claire is, she's busy, she's climbing on the wall, she's playful, she's curious, 315 00:22:03,280 --> 00:22:05,280 she's very, very chatty. 316 00:22:05,280 --> 00:22:08,800 And sometimes it's like she doesn't have any symptoms. 317 00:22:08,800 --> 00:22:12,600 No cough, no fever, no fatigue, no decreased appetite, nothing. 318 00:22:12,600 --> 00:22:16,240 She's running around happy, nothing. 319 00:22:16,240 --> 00:22:17,720 Her exam is totally normal. 320 00:22:17,720 --> 00:22:22,560 Her sister is coughing a little bit, but that's it. 321 00:22:22,560 --> 00:22:29,680 And then the chest x-ray comes back and it looks maybe a little bit viral. 322 00:22:29,680 --> 00:22:37,360 We've all seen these chest x-ray with a bit of patchy, perihyal or thickening, not too 323 00:22:37,360 --> 00:22:42,520 much, in any other child we would be like, ah, it's fine. 324 00:22:42,520 --> 00:22:43,520 She gets an eye graph. 325 00:22:43,520 --> 00:22:49,080 We get a result of the eye graph a few days later, but it's positive. 326 00:22:49,080 --> 00:22:56,320 And then because she's been so hard to find her, the chest x-ray is not quite normal, 327 00:22:56,320 --> 00:23:01,280 we decided to admit her for gastric washing on that day. 328 00:23:01,280 --> 00:23:03,800 Met her and then do gastric washings. 329 00:23:03,800 --> 00:23:09,680 And the parents are a little bit overwhelmed, like that's not what they were expecting. 330 00:23:09,680 --> 00:23:11,960 And that's a lot more in investigations than what they thought. 331 00:23:11,960 --> 00:23:17,080 But the TB nurse who saw them was like, you know, I'm not sure about them. 332 00:23:17,080 --> 00:23:18,360 We better investigate them more. 333 00:23:18,360 --> 00:23:20,440 We might not catch them again. 334 00:23:20,440 --> 00:23:27,720 So anyway, gastric washings and the PCR on the gastric washing comes back positive and 335 00:23:27,720 --> 00:23:30,600 the resistance pattern comes back indeterminate. 336 00:23:30,600 --> 00:23:34,800 So we decided to admit her. 337 00:23:34,800 --> 00:23:38,440 Further down the line, we found out that the culture was negative and that was the only 338 00:23:38,440 --> 00:23:45,000 kind of clue that we had to diagnose it. 339 00:23:45,000 --> 00:23:47,000 And we also did a chest x-ray on a sister. 340 00:23:47,000 --> 00:23:52,680 Her sister had a completely normal exam, but she had a lafloral colonization and an error 341 00:23:52,680 --> 00:23:59,960 bronchogram on her x-ray and a hyaluradenopathy. 342 00:23:59,960 --> 00:24:04,480 She had a negative IGRA and her gastric washings were negative. 343 00:24:04,480 --> 00:24:09,240 So you can see how the clues to diagnose are quite challenging. 344 00:24:09,240 --> 00:24:14,880 Anyways, so we decide that we're going to treat them both as active because we know 345 00:24:14,880 --> 00:24:17,280 that they had a really high risk contact. 346 00:24:17,280 --> 00:24:20,920 You know, we have a positive IGRA, we have a positive PCR in one kid and abnormal chest 347 00:24:20,920 --> 00:24:21,920 x-ray in the other kid. 348 00:24:21,920 --> 00:24:22,920 So we decide to treat them. 349 00:24:22,920 --> 00:24:25,200 Okay, we give them their first dose in hospital. 350 00:24:25,200 --> 00:24:26,200 It goes well. 351 00:24:26,200 --> 00:24:27,200 They go back home. 352 00:24:27,200 --> 00:24:30,080 And then a couple of weeks pass. 353 00:24:30,080 --> 00:24:34,720 And then we start getting calls every day by the TB workers in the community who are 354 00:24:34,720 --> 00:24:40,240 giving them their directly observed therapy in the community because they're struggling 355 00:24:40,240 --> 00:24:41,240 with Claire. 356 00:24:41,240 --> 00:24:46,000 So they go to the house every day and then no one opens the door. 357 00:24:46,000 --> 00:24:47,720 Everyone is sleeping. 358 00:24:47,720 --> 00:24:50,280 The kids have a reversed sleep cycle. 359 00:24:50,280 --> 00:24:52,280 They sleep all day. 360 00:24:52,280 --> 00:24:54,920 Even when they get into the house, it's impossible to wake up. 361 00:24:54,920 --> 00:24:58,120 They spend two hours at her house every day. 362 00:24:58,120 --> 00:25:03,600 And when she does wake up, she bites the TB workers, she spits on them, she swears at 363 00:25:03,600 --> 00:25:04,600 them. 364 00:25:04,600 --> 00:25:11,440 And the workers are actually becoming afraid of her. 365 00:25:11,440 --> 00:25:17,360 And so when that occurs, we try to mix the TB meds and all sorts of, you know, nice tasting 366 00:25:17,360 --> 00:25:18,360 things. 367 00:25:18,360 --> 00:25:21,600 We try to eat sandwiches, we try to eat slushies. 368 00:25:21,600 --> 00:25:29,240 We try on a day where people were partially desperate, we tried Red Bull. 369 00:25:29,240 --> 00:25:30,960 And that didn't work. 370 00:25:30,960 --> 00:25:35,480 She kept on spitting and biting and everybody was getting worked up and traumatized through 371 00:25:35,480 --> 00:25:36,480 all of this. 372 00:25:36,480 --> 00:25:40,560 For her and the TB workers, it was just awful. 373 00:25:40,560 --> 00:25:45,280 Then we tried to bring her to the clinic to give her the medicine there. 374 00:25:45,280 --> 00:25:47,480 We tried to hold her down. 375 00:25:47,480 --> 00:25:50,560 We tried to put NG tubes. 376 00:25:50,560 --> 00:25:52,680 That wasn't working. 377 00:25:52,680 --> 00:25:57,720 And we tried incentives, incentives for her family, incentives for her, like age appropriate 378 00:25:57,720 --> 00:25:58,720 toys, sticker charts. 379 00:25:58,720 --> 00:26:02,240 We tried to give her candy. 380 00:26:02,240 --> 00:26:07,120 We tried to talk to the family to say, like, you know, how do you have anything that you 381 00:26:07,120 --> 00:26:10,240 need in your house that we could help with? 382 00:26:10,240 --> 00:26:14,200 The TB workers were bringing groceries every day to help with food insecurity. 383 00:26:14,200 --> 00:26:18,040 We wrote letters for housing. 384 00:26:18,040 --> 00:26:24,720 And then eventually we had meetings with several community members, meetings with elders, with 385 00:26:24,720 --> 00:26:29,600 the holistic program in the community where we live. 386 00:26:29,600 --> 00:26:35,600 Try to kind of have everyone on board to make this child take her treatment. 387 00:26:35,600 --> 00:26:40,160 And everybody was very much on board, but the child would just not take her treatment. 388 00:26:40,160 --> 00:26:43,240 And we worked at that for quite a few weeks. 389 00:26:43,240 --> 00:26:48,360 Meanwhile, she remained well, she was clinically fine. 390 00:26:48,360 --> 00:26:54,240 But people in her community and her parents and the TB workers were getting pretty worked 391 00:26:54,240 --> 00:26:59,440 up because there were several bad outcomes at the same time from tuberculosis in that 392 00:26:59,440 --> 00:27:00,440 same community. 393 00:27:00,440 --> 00:27:07,880 So people were in the ICU, there was a death in a young person, not a child, but people 394 00:27:07,880 --> 00:27:11,720 were quite afraid for her. 395 00:27:11,720 --> 00:27:13,600 We needed to do something. 396 00:27:13,600 --> 00:27:21,560 So in the end, we held another meeting with the family and elders in the community. 397 00:27:21,560 --> 00:27:29,680 And we decided to bring the child to Saskatoon and work with the child life program to work 398 00:27:29,680 --> 00:27:36,000 on medical play and trauma associated to health care that we could eventually give her her 399 00:27:36,000 --> 00:27:37,000 treatment. 400 00:27:37,000 --> 00:27:40,280 And so she worked with them every day for several weeks. 401 00:27:40,280 --> 00:27:45,200 And after a few weeks, she was able to take her medicine after a few hours. 402 00:27:45,200 --> 00:27:48,640 And eventually after a month, she was taking the medicine on her own. 403 00:27:48,640 --> 00:27:50,320 So it took a very long time. 404 00:27:50,320 --> 00:27:54,400 But then she went back to her community and finished her treatment. 405 00:27:54,400 --> 00:28:01,440 We had to repeat her treatment entirely because we lost the time and we restarted and then 406 00:28:01,440 --> 00:28:05,040 we couldn't trust that she had the right number of doses anyways. 407 00:28:05,040 --> 00:28:10,360 But through that and the excellent work that child life and her parents and all the efforts 408 00:28:10,360 --> 00:28:16,680 that were done, we were able to finally complete her treatment. 409 00:28:16,680 --> 00:28:18,800 And so was her sister. 410 00:28:18,800 --> 00:28:24,840 So her sister struggled less, but she was seeing less and it was also difficult for 411 00:28:24,840 --> 00:28:25,840 her anyways. 412 00:28:25,840 --> 00:28:31,120 And so when they both finished their treatment, we had a little celebration with cake and 413 00:28:31,120 --> 00:28:34,600 we had identified something that they wanted for the end of their treatment. 414 00:28:34,600 --> 00:28:40,080 So they both got an iPad and it was very lovely. 415 00:28:40,080 --> 00:28:47,000 And everybody was so proud of what they've accomplished and the good things that everybody 416 00:28:47,000 --> 00:28:49,520 had done through that. 417 00:28:49,520 --> 00:28:52,480 But it was very difficult. 418 00:28:52,480 --> 00:29:02,160 And it even raised some concerns for the TV program about trust building in the community. 419 00:29:02,160 --> 00:29:08,880 We knew that there had been some bad outcome and there was potential danger in losing the 420 00:29:08,880 --> 00:29:11,240 family and the community's trust. 421 00:29:11,240 --> 00:29:13,520 And we had to navigate that very carefully. 422 00:29:13,520 --> 00:29:16,680 And not too forcefully, right? 423 00:29:16,680 --> 00:29:23,480 Because the circumstances in Canada is so linked to colonialism and racism and medical 424 00:29:23,480 --> 00:29:24,600 trauma, et cetera. 425 00:29:24,600 --> 00:29:29,360 So these are very sensitive areas to navigate. 426 00:29:29,360 --> 00:29:34,720 Wow, that is very challenging, but I mean, definitely rewarding. 427 00:29:34,720 --> 00:29:40,240 So like definitely Pat and your guys is back because that is impressive to go through all 428 00:29:40,240 --> 00:29:41,240 of those challenges. 429 00:29:41,240 --> 00:29:49,880 I mean, there was so many challenges with like diagnosing in this case, access to care, 430 00:29:49,880 --> 00:29:56,000 just transportation in general, actually basic health needs that weren't being met, that 431 00:29:56,000 --> 00:29:58,960 was probably also creating a huge challenge in this case. 432 00:29:58,960 --> 00:30:07,160 And this is not uncommon for a lot of provinces or centers that are experiencing TV outbreaks 433 00:30:07,160 --> 00:30:08,160 as well. 434 00:30:08,160 --> 00:30:12,160 And so I think a lot of our listeners probably relate to that. 435 00:30:12,160 --> 00:30:16,560 So in terms of, I mean, one thing I took from this was that you need to have a multidisciplinary 436 00:30:16,560 --> 00:30:17,560 team. 437 00:30:17,560 --> 00:30:18,560 Like that is huge. 438 00:30:18,560 --> 00:30:19,560 Yeah, it is huge. 439 00:30:19,560 --> 00:30:20,560 Yes. 440 00:30:20,560 --> 00:30:21,560 We don't have a social worker in our program. 441 00:30:21,560 --> 00:30:22,560 Yeah. 442 00:30:22,560 --> 00:30:23,560 So that's what I mean, right? 443 00:30:23,560 --> 00:30:30,440 It's like if you need a program to be running this efficiently, like this to me, I mean, 444 00:30:30,440 --> 00:30:32,880 obviously I'm looking at it from an outside viewpoint. 445 00:30:32,880 --> 00:30:33,880 I know the end outcome. 446 00:30:33,880 --> 00:30:39,560 I'm sure it was like there's many more hurdles in between that we didn't even speak about 447 00:30:39,560 --> 00:30:40,560 during the case. 448 00:30:40,560 --> 00:30:47,080 But in general, I mean, just looking at, you know, without having multiple people involved 449 00:30:47,080 --> 00:30:52,120 in this case, there would be a limited chance to run a program so efficiently. 450 00:30:52,120 --> 00:30:57,360 You need to have, you know, just the morale to first of all, because it's very, it's almost 451 00:30:57,360 --> 00:31:03,000 like difficult to continue pushing yourself to try to advocate that we need treatment, 452 00:31:03,000 --> 00:31:08,320 you know, and we all talk about, you know, how the diagnosis is difficult. 453 00:31:08,320 --> 00:31:12,160 And you know, all of us kind of hone in on that, that it's very difficult to diagnose. 454 00:31:12,160 --> 00:31:18,480 But I mean, treatment, like, I mean, I personally, if I had to take a medication for like six 455 00:31:18,480 --> 00:31:21,320 months or longer, I think it's challenging. 456 00:31:21,320 --> 00:31:26,800 And now we're asking like children, you know, to do this for a long period of time. 457 00:31:26,800 --> 00:31:31,600 So I think, I mean, a couple of things that maybe our programs need to also look into 458 00:31:31,600 --> 00:31:39,200 is that as TB increases and pediatric TB is increasing, maybe we need to increase our 459 00:31:39,200 --> 00:31:41,960 resources to make it more child friendly, too. 460 00:31:41,960 --> 00:31:42,960 Right. 461 00:31:42,960 --> 00:31:48,560 So I think you mentioned some good ways of, you know, hiding the medication into different 462 00:31:48,560 --> 00:31:49,560 tasteful foods. 463 00:31:49,560 --> 00:31:55,280 That's an approach that I think all pediatricians are used to doing, especially in our infectious 464 00:31:55,280 --> 00:31:58,320 disease world, because not antibiotics also don't taste great. 465 00:31:58,320 --> 00:31:59,480 A lot of them. 466 00:31:59,480 --> 00:32:01,840 So yeah. 467 00:32:01,840 --> 00:32:06,520 And so, but definitely, I think coming up with like having child life support rates, 468 00:32:06,520 --> 00:32:10,040 when not every center would have that ability, right. 469 00:32:10,040 --> 00:32:17,280 And so I think a lot of programs should likely reassess, you know, and have to reassess what 470 00:32:17,280 --> 00:32:21,200 resources they have and like what resources they may need. 471 00:32:21,200 --> 00:32:27,840 If we continue to see, obviously, this much pediatric TB and complicated pediatric TB, 472 00:32:27,840 --> 00:32:33,640 where, you know, it's not just the complications around the actual diagnosis and using medication 473 00:32:33,640 --> 00:32:39,440 that's like resistant, because I know an adult TB, a lot of times will face a lot of resistance 474 00:32:39,440 --> 00:32:45,880 or even, you know, foreign born children that are coming into Canada and they have tuberculosis, 475 00:32:45,880 --> 00:32:49,520 you see a lot of their resistance as a complication. 476 00:32:49,520 --> 00:32:54,880 But in this case, I mean, it was already complicated enough to know that the sister didn't even 477 00:32:54,880 --> 00:33:00,080 have some of the, you know, clinical findings, whether she's living in the house and she 478 00:33:00,080 --> 00:33:01,440 has the symptoms. 479 00:33:01,440 --> 00:33:06,720 And then she has these diagnostic tests that are not indicative of TB, right. 480 00:33:06,720 --> 00:33:09,400 So wow, that's challenging. 481 00:33:09,400 --> 00:33:14,360 So I guess one question I want to pose, and it is about the diagnosis, because I get asked 482 00:33:14,360 --> 00:33:17,640 this question multiple times a day. 483 00:33:17,640 --> 00:33:23,920 And so I think it's nice to address is the, I guess, the difference between so when do 484 00:33:23,920 --> 00:33:27,280 we know like TST versus IGRA? 485 00:33:27,280 --> 00:33:30,280 And like, what is our reliability? 486 00:33:30,280 --> 00:33:36,720 And if somebody is a contact, like how the sister was in this case, but her IGRA was 487 00:33:36,720 --> 00:33:41,000 negative, but she's a contact, I mean, in this case, you guys started her own treatment 488 00:33:41,000 --> 00:33:44,360 and you prevented any long term complications in her. 489 00:33:44,360 --> 00:33:48,560 Is that the approach that you would use in most children then? 490 00:33:48,560 --> 00:33:52,880 Yes, the answer to this is complicated. 491 00:33:52,880 --> 00:33:59,640 And I think as like the more I progress with learning about TB and doing TB work is one 492 00:33:59,640 --> 00:34:02,920 needs to be comfortable navigating the gray. 493 00:34:02,920 --> 00:34:09,880 Yeah, there is no black and white answers, especially in pediatric TB. 494 00:34:09,880 --> 00:34:17,640 So the official answer is for IGRA and skin test, so skin test meant to TST is all equivalent, 495 00:34:17,640 --> 00:34:18,640 right? 496 00:34:18,640 --> 00:34:27,000 So we have good evidence to say that screening for kids older than five years old, IGRA is 497 00:34:27,000 --> 00:34:28,880 equivalent to TST. 498 00:34:28,880 --> 00:34:32,960 For kids who don't need serial testing, IGRA is appropriate. 499 00:34:32,960 --> 00:34:38,200 The problem with IGRA is that it's often not available in smaller communities, smaller 500 00:34:38,200 --> 00:34:41,640 centers, it's a very finicky lab to get. 501 00:34:41,640 --> 00:34:45,760 We often don't have access to that other than in hospitals. 502 00:34:45,760 --> 00:34:49,960 And then TST is always fine to do in everyone. 503 00:34:49,960 --> 00:34:54,960 From two to five years old, there's a little bit of a gray zone where we think that IGRA 504 00:34:54,960 --> 00:34:58,480 is probably fine, but we don't have the greatest evidence. 505 00:34:58,480 --> 00:35:01,360 And under two, we also think it's probably working. 506 00:35:01,360 --> 00:35:05,440 We have a little bit of evidence, I think it is coming, but we don't have hard evidence 507 00:35:05,440 --> 00:35:09,440 to be able to say for sure, use an IGRA and TST. 508 00:35:09,440 --> 00:35:15,040 In the end, oftentimes in kids where you really want to make sure, sometimes you might do 509 00:35:15,040 --> 00:35:20,000 both and that might be helpful. 510 00:35:20,000 --> 00:35:28,120 But the end of the story is an IGRA or a TST helps you identifying TB infection and not 511 00:35:28,120 --> 00:35:29,560 TB disease. 512 00:35:29,560 --> 00:35:36,560 And oftentimes, especially in kids, the smallest, the more often you will see this is that in 513 00:35:36,560 --> 00:35:42,040 active disease, they'll have energy and their TST will be negative and their IGRA will be 514 00:35:42,040 --> 00:35:43,040 negative. 515 00:35:43,040 --> 00:35:49,920 It is reported as being 30 to 40% of cases of active TB, which is huge. 516 00:35:49,920 --> 00:35:56,640 And so a negative screening test doesn't rule out in any way TB infection or TB disease. 517 00:35:56,640 --> 00:36:02,560 Now you have to work with your risk factors and exposure and epi data to see how much 518 00:36:02,560 --> 00:36:06,680 important, to decide how much importance you're going to put on a negative test. 519 00:36:06,680 --> 00:36:12,440 And that's the great, the great patient comes handy. 520 00:36:12,440 --> 00:36:15,760 So for them, these sisters, they had a clear epi link. 521 00:36:15,760 --> 00:36:21,400 They were exposed to a four plus mere positive pulmonary case for extended periods of time. 522 00:36:21,400 --> 00:36:26,880 Both of them had symptoms and we did have bacteriological confirmation for one of them. 523 00:36:26,880 --> 00:36:31,720 So it all made sense despite screening tests in the older girls. 524 00:36:31,720 --> 00:36:38,080 But in someone who doesn't have contact, no risk factors, no symptoms, no imaging, well, 525 00:36:38,080 --> 00:36:41,040 you might ask yourself, why did you do the screening test first? 526 00:36:41,040 --> 00:36:46,880 But the negative test doesn't, you know, might need more. 527 00:36:46,880 --> 00:36:47,880 Right. 528 00:36:47,880 --> 00:36:48,880 Okay. 529 00:36:48,880 --> 00:36:49,880 No, that's fair. 530 00:36:49,880 --> 00:36:50,880 Yeah. 531 00:36:50,880 --> 00:36:56,640 So anybody who sees TB or manages TB or has, you know, been around, like even our pharmacists 532 00:36:56,640 --> 00:37:01,160 who have been around anybody who's managing TB kind of knows that there's always this 533 00:37:01,160 --> 00:37:02,160 gray zone. 534 00:37:02,160 --> 00:37:10,840 And if the kind of the clinical picture is there, then it's probably more likely reliable 535 00:37:10,840 --> 00:37:11,840 in that case. 536 00:37:11,840 --> 00:37:12,840 Yeah. 537 00:37:12,840 --> 00:37:14,520 And then you have that contact, right? 538 00:37:14,520 --> 00:37:15,520 So yeah. 539 00:37:15,520 --> 00:37:18,800 And I, that might be me being careful. 540 00:37:18,800 --> 00:37:24,600 And I think everyone, you know, works differently depending on their experience and their comfort 541 00:37:24,600 --> 00:37:25,600 level. 542 00:37:25,600 --> 00:37:35,240 But especially if there's an epi link, I verge on the, on treating, other than, and especially 543 00:37:35,240 --> 00:37:37,520 treating for latent when I'm not sure. 544 00:37:37,520 --> 00:37:43,360 I either wait and observe if they're well, which we can totally do that, right? 545 00:37:43,360 --> 00:37:47,560 TB will eventually declare itself or treat. 546 00:37:47,560 --> 00:37:48,560 Yeah. 547 00:37:48,560 --> 00:37:49,560 That's fair. 548 00:37:49,560 --> 00:37:50,560 Okay. 549 00:37:50,560 --> 00:37:57,040 So before we move on to the third case, I want to just touch on, you mentioned the stigma 550 00:37:57,040 --> 00:37:59,480 around TB. 551 00:37:59,480 --> 00:38:06,040 So are there resources or, you know, like as healthcare professionals, like for us, 552 00:38:06,040 --> 00:38:09,200 like are there, I mean, we mentioned that we don't have a social worker on our team, 553 00:38:09,200 --> 00:38:15,200 but in general, like, are there some resources that we can help families with the stigma? 554 00:38:15,200 --> 00:38:19,920 And obviously, I mean, you know, they like, we can, what's something that we can lessen 555 00:38:19,920 --> 00:38:25,000 the burden on them, because I know that could be very challenging, especially in some of 556 00:38:25,000 --> 00:38:28,920 these communities that you're going to, and you're working in and have outbreaks. 557 00:38:28,920 --> 00:38:36,280 I mean, it's very difficult for people to not, you know, find out or know what's going 558 00:38:36,280 --> 00:38:37,280 on, right? 559 00:38:37,280 --> 00:38:42,920 So is there any kind of guidance that you would give since you've had, you've had some 560 00:38:42,920 --> 00:38:47,720 experience in some of these northern communities? 561 00:38:47,720 --> 00:38:52,120 It's something that I find very difficult to navigate. 562 00:38:52,120 --> 00:38:58,560 And it often comes to relationship building and trust building and forming relationships 563 00:38:58,560 --> 00:39:04,520 with the entire community, knowing the place that you work in and knowing the TB workers 564 00:39:04,520 --> 00:39:13,320 and the elders and finding out if possible, what is it that people are worried about, 565 00:39:13,320 --> 00:39:15,160 goes a long way. 566 00:39:15,160 --> 00:39:21,480 And the consistency in the people working in those specific community can also be very 567 00:39:21,480 --> 00:39:22,480 helpful. 568 00:39:22,480 --> 00:39:26,760 But, you know, again, that's easier said than done. 569 00:39:26,760 --> 00:39:30,840 In the new Canadian TB guidelines that were just published in the spring, there is an 570 00:39:30,840 --> 00:39:39,080 entire chapter that's dedicated to kind of cross-cultural care and working in communities 571 00:39:39,080 --> 00:39:44,600 that have been traditionally stigmatized and marginalized, which is a really good resource 572 00:39:44,600 --> 00:39:48,800 for a health care provider that I would encourage you to read. 573 00:39:48,800 --> 00:39:57,240 But in terms of people living that life, you know, there's lots of people who have memories 574 00:39:57,240 --> 00:40:03,000 of being in the sanatorium and being taken away from their family and their years and 575 00:40:03,000 --> 00:40:10,080 all of that is very traumatizing and still very present in people's minds and lives. 576 00:40:10,080 --> 00:40:18,000 And so addressing this slowly and gently, I think is helpful. 577 00:40:18,000 --> 00:40:24,120 But also, and again, I feel this is almost cliche to say, you know, but again, addressing 578 00:40:24,120 --> 00:40:34,480 the reasons why people found themselves in that place, right, it's because of, you know, 579 00:40:34,480 --> 00:40:39,760 societal mistreatment over generation, living in poverty, unstable housing that's not been 580 00:40:39,760 --> 00:40:50,120 updated and security and all of that weighs a lot more in people's minds. 581 00:40:50,120 --> 00:40:56,400 And so addressing that will also help with trust building. 582 00:40:56,400 --> 00:40:59,480 And it's so important to the work that we do. 583 00:40:59,480 --> 00:41:04,960 Like we couldn't treat TB if we didn't have the resources to support that somewhat, even 584 00:41:04,960 --> 00:41:06,520 though whatever we're doing is insufficient. 585 00:41:06,520 --> 00:41:09,520 Yeah, well, that's a really good point. 586 00:41:09,520 --> 00:41:11,240 Yeah, it's challenging. 587 00:41:11,240 --> 00:41:18,880 I mean, it's something that's going to take a lot more years probably and a lot of support. 588 00:41:18,880 --> 00:41:23,120 And I think having the resources that we have now, I mean, I think we're already definitely 589 00:41:23,120 --> 00:41:24,960 better than we were a few years back. 590 00:41:24,960 --> 00:41:27,600 And I think everything is moving in the right direction. 591 00:41:27,600 --> 00:41:29,000 Yeah, I agree. 592 00:41:29,000 --> 00:41:35,720 And I actually, I work with this wonderful TB nurse that is a mentor to me. 593 00:41:35,720 --> 00:41:40,600 And she said, you know, I think people in the communities where there are currently 594 00:41:40,600 --> 00:41:46,480 outbreaks and are potentially communities are isolated and traditionally stigmatized 595 00:41:46,480 --> 00:41:49,440 by the rest of society. 596 00:41:49,440 --> 00:41:54,760 People are doing a beautiful thing, seeking care and bringing their children to medical 597 00:41:54,760 --> 00:42:03,600 attention and accepting the screening and participating in contact tracing. 598 00:42:03,600 --> 00:42:08,160 They're working for their community and this is what is most helpful. 599 00:42:08,160 --> 00:42:11,840 And showing this and putting light on this. 600 00:42:11,840 --> 00:42:16,960 I think for my small, small, you know, ignorant perspective might help with decreasing the 601 00:42:16,960 --> 00:42:20,200 stigma, you know, and putting power back into people. 602 00:42:20,200 --> 00:42:22,280 Yeah, no, that's a fair point. 603 00:42:22,280 --> 00:42:27,480 And really like commending like those that do come forward for screening and saying, 604 00:42:27,480 --> 00:42:32,600 you know, that there were a case or they have symptoms, that type of thing, despite the 605 00:42:32,600 --> 00:42:33,600 stigma. 606 00:42:33,600 --> 00:42:36,640 So I think that's actually a very good point you bring up. 607 00:42:36,640 --> 00:42:42,760 These good outcomes of success stories of patients who finished their treatments are 608 00:42:42,760 --> 00:42:43,760 helpful. 609 00:42:43,760 --> 00:42:49,240 We did notice even after that case that people would come to the clinic worried about TB, 610 00:42:49,240 --> 00:42:53,920 being like my kids were in contact with X person and X person, should I be worried and 611 00:42:53,920 --> 00:42:54,920 asking more about it? 612 00:42:54,920 --> 00:43:01,560 And this is what we're hoping for, you know, and I think that's an extraordinary thing. 613 00:43:01,560 --> 00:43:02,560 Yeah. 614 00:43:02,560 --> 00:43:03,560 Yeah. 615 00:43:03,560 --> 00:43:05,000 And I love the idea of like celebrating at the end. 616 00:43:05,000 --> 00:43:06,000 That was great. 617 00:43:06,000 --> 00:43:07,000 I love the parties. 618 00:43:07,000 --> 00:43:08,000 That's awesome. 619 00:43:08,000 --> 00:43:09,000 That's great. 620 00:43:09,000 --> 00:43:10,000 All right. 621 00:43:10,000 --> 00:43:16,240 So why don't we move on to the third and the final case for today? 622 00:43:16,240 --> 00:43:20,120 And this has just been like already it's like so informational. 623 00:43:20,120 --> 00:43:25,240 So I can't even thank you more like, you know, enough for being on the podcast today. 624 00:43:25,240 --> 00:43:26,240 It's great. 625 00:43:26,240 --> 00:43:27,240 Thank you so much. 626 00:43:27,240 --> 00:43:30,240 I mean, I could talk about this all night, but I don't have time. 627 00:43:30,240 --> 00:43:31,240 Okay. 628 00:43:31,240 --> 00:43:33,240 So let's do the third case. 629 00:43:33,240 --> 00:43:39,480 So we have a 12 year old girl who we will call Lindsay and Lindsay presented to a walking 630 00:43:39,480 --> 00:43:41,520 clinic in the fall. 631 00:43:41,520 --> 00:43:46,400 And her presenting concern was that she had a worsening back pain since the previous summer, 632 00:43:46,400 --> 00:43:50,240 but not much else in terms of other symptomatology. 633 00:43:50,240 --> 00:43:52,520 She didn't really have any red flags at that time. 634 00:43:52,520 --> 00:43:55,560 She didn't have any fever, weight loss, et cetera. 635 00:43:55,560 --> 00:43:58,520 The pain wasn't waking her up at night. 636 00:43:58,520 --> 00:44:03,040 And she came to this walking clinic in a medium sized city where TB, I imagine, wasn't necessarily 637 00:44:03,040 --> 00:44:05,000 top of mind when she was seen. 638 00:44:05,000 --> 00:44:08,840 You know, a teenager that comes with back pain, we see this every day, right? 639 00:44:08,840 --> 00:44:15,720 But in any case, there was a spine x-ray that was done at her first presentation. 640 00:44:15,720 --> 00:44:20,280 And then that showed, I wish I could show you the x-ray. 641 00:44:20,280 --> 00:44:24,600 It showed a small lytic lesion at T8. 642 00:44:24,600 --> 00:44:31,720 And the report says MRI is recommended, follow up recommended. 643 00:44:31,720 --> 00:44:36,560 And then there's a CT that's requested by the physician who saw her at the walking clinic, 644 00:44:36,560 --> 00:44:41,960 who's not like a clinic that knows her or will follow her up or anyways, but they requested 645 00:44:41,960 --> 00:44:42,960 the CT. 646 00:44:42,960 --> 00:44:46,240 And then not much happens for quite a few months. 647 00:44:46,240 --> 00:44:49,760 And eventually her parents are like, oh, right, like she still has back pain. 648 00:44:49,760 --> 00:44:50,760 There was supposed to be a CT. 649 00:44:50,760 --> 00:44:51,760 What's happening with that? 650 00:44:51,760 --> 00:44:55,720 They found the clinic and they discovered that the requisition was lost. 651 00:44:55,720 --> 00:45:02,520 That's three months post her initial presentation. 652 00:45:02,520 --> 00:45:05,960 And of course, in interim, her back pain has worsened. 653 00:45:05,960 --> 00:45:11,280 She's missed weeks of school and then she developed progressive leg weakness. 654 00:45:11,280 --> 00:45:13,320 She's not able to get up on her own. 655 00:45:13,320 --> 00:45:15,120 She falls a lot. 656 00:45:15,120 --> 00:45:19,760 And then quite worrisomely, over the last week, she noticed that she's been more constipated 657 00:45:19,760 --> 00:45:23,120 than usual and she's been having difficulty passing her urine. 658 00:45:23,120 --> 00:45:28,440 Anyways, so there's a urgent CT that's organized for that same day. 659 00:45:28,440 --> 00:45:34,920 Oh, she also developed fevers, nights fits and has lost 10 pounds since she was last 660 00:45:34,920 --> 00:45:35,920 year. 661 00:45:35,920 --> 00:45:36,920 So there you go. 662 00:45:36,920 --> 00:45:44,920 And then the CT shows that lytic lesion at T8 that's grown is destructive. 663 00:45:44,920 --> 00:45:48,840 There's destruction of the vertebral bodies and posterior elements. 664 00:45:48,840 --> 00:45:54,920 And then the report says these findings are very concerning for Ewing sarcoma or lymphoma. 665 00:45:54,920 --> 00:45:57,400 Possibly a CRMO should be explored. 666 00:45:57,400 --> 00:45:58,400 Infection is less likely. 667 00:45:58,400 --> 00:46:02,040 And I think we're actually involved in this case. 668 00:46:02,040 --> 00:46:07,720 You probably remember that. 669 00:46:07,720 --> 00:46:12,880 So after that CT, that same day, she's sent from that mid-level city to a tertiary care 670 00:46:12,880 --> 00:46:14,160 center that same day. 671 00:46:14,160 --> 00:46:19,320 And she's admitted under ortho and oncology is consulted. 672 00:46:19,320 --> 00:46:25,120 And she has a workup that's initiated for sarcoma with a full body PET CT and MRI of 673 00:46:25,120 --> 00:46:26,120 her spine. 674 00:46:26,120 --> 00:46:31,200 Both ortho and oncology reports very likely malignancy. 675 00:46:31,200 --> 00:46:35,120 The MRI report, PET CT report also say that. 676 00:46:35,120 --> 00:46:41,840 And there's an order that's booked the next day for decompression of her spine. 677 00:46:41,840 --> 00:46:46,000 And then on the PET CT, they're described that lytic lesion from the CT, but there's 678 00:46:46,000 --> 00:46:50,480 also another lesion at T5 that's suspicious for Mets. 679 00:46:50,480 --> 00:46:55,920 And she has a small parol effusion with a small parol nodule that they say is also suspicious 680 00:46:55,920 --> 00:46:56,920 for Mets. 681 00:46:56,920 --> 00:46:59,000 Her lung parenchyma is normal. 682 00:46:59,000 --> 00:47:02,320 And the rest of her PET CT is normal. 683 00:47:02,320 --> 00:47:10,880 And then we think about consulting Dr. Purwil for rule out infection before her OR. 684 00:47:10,880 --> 00:47:16,560 And Dr. Purwil, who's seen crazier things, says, you know, make sure you send samples 685 00:47:16,560 --> 00:47:20,960 for TV in addition to all of these other things. 686 00:47:20,960 --> 00:47:27,040 In doing her very thorough history, like these ID likes to do, I think you found out that 687 00:47:27,040 --> 00:47:30,280 she had ties to one of the communities where there was outbreak. 688 00:47:30,280 --> 00:47:37,560 She actually went back and forth from this community and spent a lot of time there even 689 00:47:37,560 --> 00:47:39,600 before her symptoms started. 690 00:47:39,600 --> 00:47:46,120 She even lived in that community for years before she went to high school. 691 00:47:46,120 --> 00:47:48,160 Anyways, that's in the background. 692 00:47:48,160 --> 00:47:51,160 While she's going to the OR, the decompress is fine. 693 00:47:51,160 --> 00:47:52,440 It's a very long surgery. 694 00:47:52,440 --> 00:47:53,720 There's two surgeons involved. 695 00:47:53,720 --> 00:47:56,960 It was very, very complex. 696 00:47:56,960 --> 00:47:58,240 But you resect the mass. 697 00:47:58,240 --> 00:48:00,520 And then they send the sample for PATH. 698 00:48:00,520 --> 00:48:05,120 And on the same day, we get a preliminary report, no malignant cells. 699 00:48:05,120 --> 00:48:10,040 There's granulomethase, inflammatory infiltrates, and some necrosis in the sample, which is 700 00:48:10,040 --> 00:48:14,680 non-caziating, but nonetheless, some necrosis. 701 00:48:14,680 --> 00:48:19,480 And then we fast-tracked the TB PCR on that sample, which came back positive. 702 00:48:19,480 --> 00:48:24,040 And that's when the TB program got involved. 703 00:48:24,040 --> 00:48:27,600 And eventually, her eye graph came back positive. 704 00:48:27,600 --> 00:48:32,680 And the sample from her OR, the cultured brew, MTB, which was pen-sensitive. 705 00:48:32,680 --> 00:48:38,080 So she was treated like disseminated TB, the pleura and bone. 706 00:48:38,080 --> 00:48:43,400 She was put on 9-ounce of TB treatment with the traditional Ripe Therapy. 707 00:48:43,400 --> 00:48:46,120 And she had an excellent outcome. 708 00:48:46,120 --> 00:48:51,360 If you look at her CT images, false treatment, it's fully evolved. 709 00:48:51,360 --> 00:48:52,880 There's no sequelae at all. 710 00:48:52,880 --> 00:48:55,320 But most importantly, she's walking. 711 00:48:55,320 --> 00:49:05,640 And she doesn't have any neurological sequelae from her bony osteomyelitis tuberculosis. 712 00:49:05,640 --> 00:49:14,560 So again, I should pull the lesson from this case, are almost cliche and so classic, which 713 00:49:14,560 --> 00:49:23,520 in tuberculosis, in children, early identification is so, so, so important to avoid dramatic 714 00:49:23,520 --> 00:49:28,800 and horrible outcomes where she could have potentially been paralyzed, right? 715 00:49:28,800 --> 00:49:29,800 Yeah, exactly. 716 00:49:29,800 --> 00:49:31,600 Or have further dissemination. 717 00:49:31,600 --> 00:49:39,560 And we want to avoid deaths and horrible disability in everyone, but particularly in children. 718 00:49:39,560 --> 00:49:48,640 But also, often, when there is a mass in the picture, the malignancy will be top of mind. 719 00:49:48,640 --> 00:49:55,000 And people will not necessarily think about including TB in their differential unless 720 00:49:55,000 --> 00:50:01,520 there is clear causes, clear links to epi. 721 00:50:01,520 --> 00:50:04,920 You did have, but they were a little bit difficult to find. 722 00:50:04,920 --> 00:50:07,040 Yeah, yeah, no, for sure. 723 00:50:07,040 --> 00:50:11,880 And I do remember this case being challenging in the sense that, I mean, most of the time, 724 00:50:11,880 --> 00:50:17,280 you know, and I always teach my learners this too, is that it's really, really, really difficult 725 00:50:17,280 --> 00:50:22,080 when you're called and somebody says, oh, this is a mass, you know, like, because mass 726 00:50:22,080 --> 00:50:26,120 in everybody's mind, you know, tunnel visions you to malignancy. 727 00:50:26,120 --> 00:50:31,880 Especially when all of the reports and all of the subspecialists kind of grasp that and 728 00:50:31,880 --> 00:50:34,560 say, yes, it fits, etc, etc. 729 00:50:34,560 --> 00:50:35,560 Exactly. 730 00:50:35,560 --> 00:50:39,520 So I think like in this case, I mean, like any other case, I always tell learners is 731 00:50:39,520 --> 00:50:45,520 like, you have to step back and remember that you go in with a clean slate, you know, take 732 00:50:45,520 --> 00:50:51,200 your history, find out information and getting collateral information, especially like teenage 733 00:50:51,200 --> 00:50:55,960 patient, teenager patients, I've noticed is like really important because sometimes they 734 00:50:55,960 --> 00:50:58,440 can't remember, I mean, life is changing, right? 735 00:50:58,440 --> 00:51:00,520 Like things are happening all the time. 736 00:51:00,520 --> 00:51:02,840 You know, everything's a blur. 737 00:51:02,840 --> 00:51:08,400 And so it's, I think, really important to be asking parents and, you know, whoever else 738 00:51:08,400 --> 00:51:11,120 is in close contact with the family, that type of thing. 739 00:51:11,120 --> 00:51:16,800 So I'm really not getting tunnel visioned and it's it's so difficult, though, because 740 00:51:16,800 --> 00:51:21,360 I mean, especially for consultants, because you're told here's the clinical question. 741 00:51:21,360 --> 00:51:25,960 Can you help us like an ID is a little bit different because every video is can you rule 742 00:51:25,960 --> 00:51:32,720 out infectious disease, you know, I wish there was like a list of 10 diseases that I could 743 00:51:32,720 --> 00:51:33,720 rule out for everybody. 744 00:51:33,720 --> 00:51:37,360 But, you know, but in the end of the day, it's, it's our job, right? 745 00:51:37,360 --> 00:51:42,760 Like, just like how you're you're a detective in TV world, I'm like a detective in the infectious 746 00:51:42,760 --> 00:51:43,760 disease world, right? 747 00:51:43,760 --> 00:51:49,000 So like, I have to put the pieces together and always remembering that the story has 748 00:51:49,000 --> 00:51:51,240 to fit, right? 749 00:51:51,240 --> 00:51:58,080 And if there's something off about the story, like the age group or the presentation, then 750 00:51:58,080 --> 00:52:03,320 always reconsidering, like, maybe this isn't the diagnosis, and maybe I should think, you 751 00:52:03,320 --> 00:52:04,560 know, maybe there's other things. 752 00:52:04,560 --> 00:52:08,760 And that's why we do all these tests, right, so that we can actually let me most of the 753 00:52:08,760 --> 00:52:15,200 time, it's to rule out certain diseases, you know, and like, some of the times they rule 754 00:52:15,200 --> 00:52:17,720 them in, which is great. 755 00:52:17,720 --> 00:52:22,800 And and, I mean, knowing that the utility of like, we're very lucky, because we have 756 00:52:22,800 --> 00:52:29,800 a lab that can do, you know, PCR based tests for us quite quickly on kind of requests, 757 00:52:29,800 --> 00:52:33,720 even I think that I remember this case being on a weekend. 758 00:52:33,720 --> 00:52:40,480 So it was a Friday afternoon, and like Saturday morning, we had the PCR result back, right? 759 00:52:40,480 --> 00:52:44,200 So I think like, we're fortunate that we're in a center that we're able to do that. 760 00:52:44,200 --> 00:52:46,480 And some centers may not have the capacity to do that. 761 00:52:46,480 --> 00:52:51,480 But just remembering that if you have, you know, quicker diagnosis, and we knew that 762 00:52:51,480 --> 00:52:55,240 going into this, we're going to get a good tissue sample. 763 00:52:55,240 --> 00:52:59,000 So tissue is ideal, right for sampling. 764 00:52:59,000 --> 00:53:03,640 So whenever in my world, if a tissue is positive or something, I mean, the yield is there. 765 00:53:03,640 --> 00:53:04,640 Right. 766 00:53:04,640 --> 00:53:05,640 So we can send it off. 767 00:53:05,640 --> 00:53:10,160 And, and we always talk about in guidelines, like if it's fluid and for even sputum, and 768 00:53:10,160 --> 00:53:14,760 there's less than, you know, a small amount like less than a mil, we always make sure 769 00:53:14,760 --> 00:53:20,880 that culture is sent over PCR molecular based testing, as per our guidelines, which is very 770 00:53:20,880 --> 00:53:25,480 accurate to do because we should be doing that so that we can actually definitively 771 00:53:25,480 --> 00:53:31,080 diagnose and then also follow the resistance patterns and sensitivities. 772 00:53:31,080 --> 00:53:34,160 But in cases where you know there's going to be an apple amount of tissue and you need 773 00:53:34,160 --> 00:53:38,520 a rapid or apple amount of specimen, you need a rapid diagnostic test to kind of help you 774 00:53:38,520 --> 00:53:43,600 rule in, I think PCR molecular based testing is definitely very helpful. 775 00:53:43,600 --> 00:53:45,680 So it was for this case, at least for me. 776 00:53:45,680 --> 00:53:46,680 So absolutely. 777 00:53:46,680 --> 00:53:47,680 Yes. 778 00:53:47,680 --> 00:53:48,680 Yes. 779 00:53:48,680 --> 00:53:50,920 And tissue and TB is always the best to yield. 780 00:53:50,920 --> 00:53:55,880 All the other samples are, you know, notably not very good. 781 00:53:55,880 --> 00:54:03,480 And so a negative sample doesn't necessarily mean anything as you know, of course. 782 00:54:03,480 --> 00:54:08,320 And then for the PCR, what is interesting is that it's not validated for many types 783 00:54:08,320 --> 00:54:09,320 of samples. 784 00:54:09,320 --> 00:54:14,000 And so often, again, if it's negative, you know, one has to remember that it doesn't 785 00:54:14,000 --> 00:54:15,400 totally rule it out. 786 00:54:15,400 --> 00:54:21,520 But when it's positive, then that definitely will give you a lot of clues towards your 787 00:54:21,520 --> 00:54:22,520 diagnosis. 788 00:54:22,520 --> 00:54:29,040 So where you can do a gene experts sample, you can use the same machine to do different 789 00:54:29,040 --> 00:54:30,040 samples. 790 00:54:30,040 --> 00:54:36,680 And I know that some remote communities have gene experts for influenza, et cetera. 791 00:54:36,680 --> 00:54:41,960 And I believe you can still and this is like, you know, non validated. 792 00:54:41,960 --> 00:54:47,440 But in a pinch, you can use this machine to test like a student sample, a gastric washing 793 00:54:47,440 --> 00:54:49,440 sample for a gene. 794 00:54:49,440 --> 00:54:51,120 Okay, that's good to know. 795 00:54:51,120 --> 00:54:57,000 I mean, especially like, you know, in a situation where you don't have much for resources or 796 00:54:57,000 --> 00:55:00,320 you can't transport the patient to a bigger center. 797 00:55:00,320 --> 00:55:01,320 Right. 798 00:55:01,320 --> 00:55:04,320 So yeah, often big obstacles. 799 00:55:04,320 --> 00:55:05,320 Yeah. 800 00:55:05,320 --> 00:55:08,600 But in terms of malignancies and TB, those are often like you said, right, there is a 801 00:55:08,600 --> 00:55:09,600 map. 802 00:55:09,600 --> 00:55:13,160 So people look at me to rule out malignancies, right? 803 00:55:13,160 --> 00:55:17,640 Because this is also what's going to kill people. 804 00:55:17,640 --> 00:55:21,040 TB and malignancy go hand in hand, you know, like malignancies. 805 00:55:21,040 --> 00:55:24,560 TB is often in the differential and vice versa. 806 00:55:24,560 --> 00:55:26,440 But it can also happen together. 807 00:55:26,440 --> 00:55:27,440 Right. 808 00:55:27,440 --> 00:55:33,880 You have seen this people with, you know, classic presentation of TB adenitis. 809 00:55:33,880 --> 00:55:40,040 But then you do a biopsy and you do find out that they have a lymphoma. 810 00:55:40,040 --> 00:55:46,040 And so you need to be careful about not missing one when the other is present, but also making 811 00:55:46,040 --> 00:55:48,040 sure that people don't have both things. 812 00:55:48,040 --> 00:55:50,640 Yeah, no, that's actually a really good point. 813 00:55:50,640 --> 00:55:51,640 Right. 814 00:55:51,640 --> 00:55:54,440 And so a lot of these like diseases that are mimickers of one another. 815 00:55:54,440 --> 00:55:55,440 Right. 816 00:55:55,440 --> 00:56:00,480 And we had a classic always talk about these indolent presentation, that type of thing. 817 00:56:00,480 --> 00:56:02,080 So the workup has to be extensive. 818 00:56:02,080 --> 00:56:03,680 But yeah, keeping a broad differential. 819 00:56:03,680 --> 00:56:04,680 Right. 820 00:56:04,680 --> 00:56:06,040 That's what we that's what we practice. 821 00:56:06,040 --> 00:56:11,080 So I think that's the end of the day, always remembering that there could be multiple things 822 00:56:11,080 --> 00:56:12,080 going on. 823 00:56:12,080 --> 00:56:19,520 And I think if you come up with a broad differential to begin with, it's easier to manage these 824 00:56:19,520 --> 00:56:20,520 cases. 825 00:56:20,520 --> 00:56:21,520 Wow. 826 00:56:21,520 --> 00:56:22,520 So super interesting. 827 00:56:22,520 --> 00:56:27,040 So we went through kind of the social concerns of managing TB. 828 00:56:27,040 --> 00:56:33,760 We talked a lot about like, you know, access to care and complicated cases in terms of, 829 00:56:33,760 --> 00:56:37,720 you know, just clinical presentations and contact tracing. 830 00:56:37,720 --> 00:56:43,280 And then another case where, you know, diagnosis sometimes is so difficult. 831 00:56:43,280 --> 00:56:51,200 And it's missed at times, and really keeping that in mind that some presentations can mimic 832 00:56:51,200 --> 00:56:52,200 TB. 833 00:56:52,200 --> 00:56:57,760 And if it is endemic, or if you're any suspicion, really getting a thorough history and really 834 00:56:57,760 --> 00:57:05,680 knowing, I think, which communities in your provinces have higher TB cases and, you know, 835 00:57:05,680 --> 00:57:07,160 keeping in touch with public health. 836 00:57:07,160 --> 00:57:10,880 And I think for some physicians, a little bit easier, like I work daily with public 837 00:57:10,880 --> 00:57:13,960 health, so they're always hearing from me. 838 00:57:13,960 --> 00:57:19,120 And so I think it's similar to like a TB program, you guys will be in close touch. 839 00:57:19,120 --> 00:57:24,360 So I think like encouraging other physicians, you know, even if you're out in the community 840 00:57:24,360 --> 00:57:31,400 practicing somewhere, it's okay to call the medical officer of health or, you know, reach 841 00:57:31,400 --> 00:57:36,440 out to your TB program and see if this is a community that maybe somebody is listed 842 00:57:36,440 --> 00:57:40,880 as a contact, because that might just guide you to the right direction and prevent any 843 00:57:40,880 --> 00:57:44,000 type of complication that we just talked about. 844 00:57:44,000 --> 00:57:46,760 So I was actually going to bring this up. 845 00:57:46,760 --> 00:57:53,280 So in Saskatchewan, I'm not sure how it works in other provinces, but I imagine it's similar. 846 00:57:53,280 --> 00:57:56,480 You know, there's a TB physician on call 24 seven. 847 00:57:56,480 --> 00:58:02,480 And as with any other consultants, it's totally okay to phone the TB physician with a question, 848 00:58:02,480 --> 00:58:03,480 like you're not sure. 849 00:58:03,480 --> 00:58:07,240 Do you think about TB in this specific case or not? 850 00:58:07,240 --> 00:58:11,200 And if so, what kind of investigation should you do? 851 00:58:11,200 --> 00:58:13,200 And that's why we're here, right? 852 00:58:13,200 --> 00:58:17,080 And we're able to see, oh, is this person part of an ongoing contact trace? 853 00:58:17,080 --> 00:58:21,000 Or maybe they were under our radar, we tried to reach them. 854 00:58:21,000 --> 00:58:25,720 And so it's useful for everyone, including the TB program to receive these, these phone 855 00:58:25,720 --> 00:58:26,720 calls. 856 00:58:26,720 --> 00:58:29,920 And I would say with kids, if you're not sure, it's always urgent. 857 00:58:29,920 --> 00:58:35,200 If TB pops in the back of your subconscious, call the TB physician. 858 00:58:35,200 --> 00:58:37,480 Yeah, that is great advice. 859 00:58:37,480 --> 00:58:38,480 Yes. 860 00:58:38,480 --> 00:58:43,920 Because sometimes, I mean, especially with even pulmonary TB, some is difficult because 861 00:58:43,920 --> 00:58:47,920 a lot of these patients are on like weeks of antibiotics first, right? 862 00:58:47,920 --> 00:58:52,920 There's like this non-improving pneumonia, which then ends up sometimes being because 863 00:58:52,920 --> 00:58:56,960 it doesn't really always have to present cavitary originally. 864 00:58:56,960 --> 00:59:01,560 And so, so I think it can be really, really challenging, but always keep in the mind in 865 00:59:01,560 --> 00:59:06,360 the back of the mind, you know, if there is any suspicion, it's better to just call and 866 00:59:06,360 --> 00:59:07,840 use your resources. 867 00:59:07,840 --> 00:59:08,840 Absolutely. 868 00:59:08,840 --> 00:59:12,440 Even if you don't have any confirmation of anything and it's just a question, it's always 869 00:59:12,440 --> 00:59:13,440 fine. 870 00:59:13,440 --> 00:59:14,440 Yeah. 871 00:59:14,440 --> 00:59:15,440 Well, that's fantastic. 872 00:59:15,440 --> 00:59:16,440 Thank you so much, Dr. Brandemeyer. 873 00:59:16,440 --> 00:59:22,840 That was like, honestly, it's just so refreshing to go through some cases because now all of 874 00:59:22,840 --> 00:59:28,120 us are always thinking about different diseases and different conditions, especially living 875 00:59:28,120 --> 00:59:30,600 in a province where it is endemic to TB. 876 00:59:30,600 --> 00:59:35,040 A lot of our listeners, you know, they've reached out and they want to talk about it. 877 00:59:35,040 --> 00:59:39,160 We know that there's TB outbreak areas here. 878 00:59:39,160 --> 00:59:42,400 And so we've gotten a lot of questions regarding it. 879 00:59:42,400 --> 00:59:47,680 And so I think this combined with the new guidelines is a really, really, really great 880 00:59:47,680 --> 00:59:48,680 resource. 881 00:59:48,680 --> 00:59:54,640 I think it's I think all learners, all physicians, you know, especially within Canada, where 882 00:59:54,640 --> 00:59:58,760 we are seeing an uptick in our cases, we should all be familiar with this. 883 00:59:58,760 --> 01:00:01,280 So I want to thank you for coming on the podcast. 884 01:00:01,280 --> 01:00:06,960 And it was a fantastic episode and we look forward to having you back again for future 885 01:00:06,960 --> 01:00:07,960 games. 886 01:00:07,960 --> 01:00:08,960 Thank you so much for having me. 887 01:00:08,960 --> 01:00:09,960 I was so honoured to be here. 888 01:00:09,960 --> 01:00:10,960 Thank you so much. 889 01:00:10,960 --> 01:00:11,960 Thanks. 890 01:00:11,960 --> 01:00:18,880 Thank you, Dr. Purwall, and thank you, Dr. Brynne-Moore, for joining us. 891 01:00:18,880 --> 01:00:20,840 Have a topic suggestion? 892 01:00:20,840 --> 01:00:28,680 Email us at thecanadianbreakpoint at gmail.com and be sure to follow us on Twitter at CABbreakpoint. 893 01:00:28,680 --> 01:00:43,360 See you again soon at the Canadian Breakpoint.