Thanks for joining us again at the Canadian Breakpoint, a Canadian infectious diseases
podcast by Canadian infectious diseases physicians.
I'm Summer Stewart, here with Dr. Rupeena Purewal, pediatric infectious diseases specialist
from Saskatoon.
In this episode, we welcome Dr. Amalia Brindamore, pediatrician with the Saskatchewan TB Prevention
and Control Program to review complicated TB cases.
Dr. Purewal.
All right, welcome to another episode of our podcast the Canadian Breakpoint.
Today we have a very special guest and actually a close friend of mine, Dr. Brindamore, who
will be talking about complicated tuberculosis cases.
So just an introduction, Dr. Amalia Brindamore is a general pediatrician with a special interest
in global health.
She works as a tuberculosis consultant with the Saskatchewan Tuberculosis Prevention and
Control Program, where she supports TB care for children and adults in several areas of
the province.
She co founded Saskatoon's Refugee Engagement and Community Health, which is known as REACH
Clinic, where she cares for refugee children with complex needs.
She also provides outreach pediatric clinic care to the northern Saskatchewan communities
of Islay Cross, Lelosh and Stony Rapids.
So welcome Dr. Brindamore.
Hello, thank you so much for inviting me.
Such an honor to be here.
No, it's an honor for us because we have somebody who is an expert in TB and a lot of provinces
are seeing complicated cases.
And so we've had a lot of requests to kind of talk about management, how do we manage
these patients and hearing it from an expert is a pleasure for us.
And actually, it's a great follow up episode because we just had Dr. De Willow on who actually
helped edit some of the Canadian TB guidelines that were updated in March 2022.
So a lot of our listeners had a chance to review these updates.
And so this is a great follow up episode.
So super excited to have you on board.
Thank you.
I think the first episode I listened to it and it's a hard act to follow.
All right.
So I think in terms of compared to our different our podcast episodes previously, this will
be a bit of a different approach.
So we'll be talking about a few cases, complicated cases where we'll walk through the overview
and the details of the case approach to managing how did the patient overall do and really
for us clinicians and other health care providers, how would we have managed this differently
and what resources do we have and keeping in mind that the cases that you're seeing
are in Saskatchewan, but definitely applicable to the rest of Canada and pretty much North
America.
So we have listeners from across the globe.
And so we're kind of excited to hear some of these cases.
And I would like to give a disclaimer that this podcast is for informational purposes
only and it does not replace an infectious disease or TB expert consult.
All right.
So with further ado, why don't we start and I'll hand over the microphone to you, Dr.
Brynner-Mor.
Thank you so much.
So I have three cases to talk about.
And the way I chose them is I chose cases that were either complex in terms of management
or complex in terms of challenging or challenges in accessing care or atypical presentations.
And then we can unpack them and go through them.
And I also wanted to illustrate what kind of outcome we're trying to prevent when we
care for these kids and why tuberculosis in kids is such urgent to look after, important
to think about and be really persistent in finding the cases and following up.
So the first case is really a tragic story.
But what I wanted to outline was, again, what we were trying to prevent when we deal with
pediatric TB.
And so that's why I chose to talk about this case first to illustrate how severe and horrible
these cases can be.
And almost 100% of the time, preventable.
So the details have been changed.
I changed the name of the communities and the name of the patients, et cetera, changed
a few details of their history so that they're not recognizable.
But this case is about four-month-old Victor and his sister Carla.
And Victor presented to a peripheral emergency department, so not in a big city, but not
in a small town either, with a two-week history of cough, wheeze, and intermittent subjective
fevers, as we say in peeps, so tactile fevers.
He was seen by the eMERGE doc who did a chest x-ray because he thought it was a little bit
prolonged and odd and he's little.
And so that chest x-ray shows diffuse patchy consolidation, worse than a ripe upper lobe,
and then this huge lesion that's described as a mass-like lesion, needing follow-up,
most likely due to infection, suggesting repeated chest x-ray in a few weeks or CT, et cetera.
So they consult peeds.
He's admitted on the ward, in the general pediatric ward for pneumonia.
He started on IV antibiotics.
And truthfully, his baby was on room air.
He was systemically super well.
He didn't really have any work of breathing.
He didn't really have any findings on physical exam other than minimal intermittent wheeze.
And so there was no rush or any acuity to that.
And so they do a CT scan the next day.
And that CT shows large necrotic, peritracheal, metastinal, and right hyaluradenopathies that
are obstructing the right mainstream bronchus.
And he has extensive consolidation in the right upper and right middle lobes.
And the report says, most likely malignancy, query TB.
And so after that CT result, which is often what we see in cases of TB is like, well,
I can't rule out infection, but most likely malignancy.
But a pediatrician looks at that, goes back to the family, and asks a few more questions.
And what they find out is that the parents are asking, do you think this could be due
to the illness that his older sister had?
And the older sister died two weeks ago from an unknown cause.
She just got found unresponsive at home and brought to the hospital where she died in
the hospital before kind of anything was done.
Other than a chest X-ray and a CT, and that chest X-ray and that CT showed extensive cavitations
and twin bud, twin bud opacities.
And there were some thoughts that perhaps her pulmonary artery was eroded and that led
to a subsequent hemorrhage, and that's how she died.
There was no samples that were taken.
And the family wasn't really kind of provided any explanation.
And so finding this out, the pediatrician in the periphery is very worried, calls the
TB program in Saskatoon and say, have you heard about this baby?
Like, is he on your radar?
Have you treated this family or this sister before?
And then of course, we've never heard about them.
We've never heard about the sister.
We've never heard about the baby.
But that story was so concerning that further investigations on Victor were done.
And so of course, not of course, this is actually atypical, but we found bacteriological confirmation
for Victor.
So they did gastric washing and the gene experts for TB was positive and the culture was positive
subsequently.
He also had an Aigra that was positive and a Mentu that was positive.
And it's rare that we get all of that.
It's rare that we get bacteriological confirmation.
Often the Aigra and the Mentu often are negative and if you don't have the epi link, it's often
very difficult to make the diagnosis.
So we were lucky on that case.
So he was started on regular pulmonary TB treatment with the RIPE regimen.
And then he did quite well.
He was followed by the TB program, had full recovery and his chest x-ray post-treatment
looked completely normal.
And he's done his treatment for a few months and he's done really well.
But then the question is, where did he catch this?
Where is this TB coming from?
So of course, the sister's case was suspicious, but we were never able to obtain samples.
We tried to do post-mortem, but that wasn't successful.
The TB nurses initiated a source-trace investigation for the baby and they also did at the same
time contact tracing investigation for his sister that they considered as an infectious
active, but that wasn't completely confirmed.
And so through these investigations, they found a link to the kid's grandma that they
were visiting often.
And his grandma had family ties with several communities up north.
And what she was doing is that she was supporting several people who had challenges with housing
in her community, including one specific person who appeared to have been coughing for a very
long time that she identified as part of the contact tracing.
This individual had no phone, no address, was very hard to find.
And the TB nurses really persisted for several weeks.
They sent letter to several family members in different communities, to his uncle, his
grandma, his siblings, they phone everybody who had a phone and were really persistent,
but they were never able to find him.
But eventually some weeks passed and then this person shows up at the TB program office
because he got all of the letters, kept them.
And then when he started coughing up blood, he said, maybe I have TB.
I'm going to go to the address that's on those letters and showed up.
And through him, who of course he had TB, they were able to do the complete genogram
that linked this person and these two kids to an area of the province where an outbreak
was eventually called a few weeks after.
And so everything kind of fell together and made sense, but it took several weeks of detective
work for the TB nurses to find that.
And in the end, so this guy is also on treatment, doing well and recovered.
Yeah.
So quite challenging in terms of like, I think, I mean, one of the challenges that I would
face in that case is to never identify difficulty identifying the index case, right?
Exactly.
And like contact tracing, especially when you don't, especially in a province like Saskatchewan,
where sometimes the address that we have provided for some of the patients isn't, you know,
their permanent address.
And so there's a lot of moving around.
And I'm sure like some learn Manitoba, they must be experiencing that as well.
So that is quite challenging for sure.
And so it's tedious detective work.
Definitely.
And, but it's really the contact tracing and the source investigations that will make everything
make sense.
So I often look at these mapping and the genograms and the family trees and it comports us in
our diagnoses, especially in pediatrics where it's so rare to get good bacteriological confirmation.
When the links and the epilinks make sense, it makes me feel better about not treating
them for nothing or over treating people when really the link is there.
Sometimes it takes a long time to find it.
Yeah.
Yeah, that's fair.
Yeah.
So how would you, is there like, I guess, locally in Saskatchewan, public health would
be able to help clinicians if they were in a situation like that, where they need to
get some help with contact tracing or is it mainly like TB control?
It depends.
It varies province by province.
I know that in some provinces, it's public health that does that.
In Saskatchewan, it's the TB program specifically that has TB nurse clinicians that are looking
after this contact tracing.
But there's lots of partnership going on, right?
We do talk to public health, talk to community health nurses in different communities.
And it takes a lot of discussion with lots of people to help with that.
But that would be in Saskatchewan, particularly the TB program that would be responsible for
that.
Okay.
Right.
Yeah.
And what's odd about this, the importance of the genogram and the importance of the
contact tracing is that through that, it's obvious to say for people doing this work
every day, but how you identify high risk contacts and prevent these outcomes from occurring
in more babies.
And so, for example, through this contact trace investigations, we were able to identify
several active adults who were in contact with several other kids and dozens of kids
needed to be profiled as a result.
We had at least five or six that I can think of active cases that were unearthed as a
contact tracing.
Wow.
Yeah.
So I guess, I mean, again, like you said, the importance of going back and finding
index stations, contact tracing, and then really preventing such severe disease.
I mean, that is the presentation.
I mean, it's already very tragic to know that a child lost their life most likely due to
that.
And then in kind of looking at even Victor's case here, that is a very severe presentation
where they're presenting with such significant CT findings.
And we, you know, that's actually disheartening to know that all of that could have been prevented.
Absolutely.
Yeah.
And then we have the classic presentation of the adenopathy is causing tracheal compression
and a fairly rapid progression, right?
He was only four months and had had symptoms for only a couple of weeks.
And that's a classic presentation of a less than one year old child who really with TB
doesn't have the classic symptoms, might show up like a viral infection that doesn't go
away and doesn't have a lot of findings on physical exam despite potentially very severe
disease.
And same thing for his sister where, you know, she had a little cough for two years and she
didn't see care.
So she wasn't identified early enough.
There was this history where maybe she went to a walking clinic a week prior to the events
treated like asthma.
There was no imaging that was done, but that's not necessarily atypical for how we would
manage other children.
So we really have to have TB, you know, at the top of my mind all the time to find these
cases.
Yeah.
And I think so kind of like a couple of like, I guess, key points that I would take back,
you know, take away from this case would be how important is to contact trace, inform
others if you're like seeing any child that might have symptoms that are consistent with
that.
And then having that high suspicion of TB in the back, especially if you have TB in
your communities and it's endemic in certain communities and really thinking like a chronic
cough and child that's not improving should probably warrant us to think about tuberculosis.
So I think for some of our first, you know, first line defense positions out there who
sometimes don't know anything about these patients, right?
Like it's very difficult for them because for instance, like walk in clinic physicians,
right?
They don't have a background history of these patients.
They don't have their family history.
And so, you know, managing patients, but just keeping that on high alert, especially in
a province like Saskatchewan where we do see a lot of endemic TB.
So those are some of the things that I would take back and bring into my practice for sure.
Is there any other key points that you think we should address maybe for some of our listeners
for this case?
Not for this case.
And I think we can go to other key points a little bit later.
I almost feel like these key points for TB are so cliche, right?
Like it could always be TB, but really, but really that's what it is.
Yeah, I know.
And to be honest, I think it's like having knowing what's common in your areas of practice,
I think is really important.
And it's always the same, you know, if it looks like it, it probably is TB.
And so we should always keep that on our differentials.
I think sometimes it's just good to familiarize ourselves and remind ourselves that it's still
on the differential.
Absolutely.
Yeah.
All right.
Do you want to walk us to the second case then?
Yes.
So this second case is not necessarily a complex case because of her presentation, but it was
really the treatment that was challenging for her and for everyone around her.
So this is four-year-old Claire.
And her case not only talks about barriers to accessing care, but also the stigma surrounding
TB that is very, very strong everywhere in the province.
So anyways, Claire is four and she was identified through contact tracing again of a smear positive
pulmonary TB case.
So she was a high risk household contact.
And because she's less than five years, it's urgent.
So we tend to see these kids or we want to see these kids quicker and we do more investigation
and have a lower threshold to see them faster than others.
So as for the guidelines, we needed a skin test right away as soon as she's identified
with a MENTU and then a repeated MENTU if that one is negative at eight weeks post-exposure.
And then all kids in that time, we do a chest x-ray in addition to symptom inquiry and a
physical exam, et cetera.
But just that was very complicated because the family struggle with unstable housing.
They didn't have a phone.
And so they were very difficult to find.
We again called everybody we could, send letters to the clinic in the community where they
lived.
We contacted family members.
And on top of all of that, it was in the middle of COVID.
So that was the first year of COVID.
So all of our clinics were canceled and we were only doing telehealth clinics, which
really isn't ideal to go look for people in their community.
And the TB workers who are really miracle workers in the community where she lives,
tried to go to their house multiple times, but people would not answer the door, would
not want to talk to them or everyone was sleeping.
Anyways, it was a hard time and it took many, many, many weeks before we could talk to them.
Then the next barrier was how do you do a chest x-ray?
You don't have a chest x-ray machine in that community and they need to drive or find some
transport to go in another community an hour and a half away to go do a chest x-ray.
This family has several children, they work.
It's very complicated to do that.
So we booked her six times for a chest x-ray and she never went to do the chest x-ray.
She did have a skin test, but she never came back to have it read.
So we can't piece out our information that we need.
So eventually we succeed in talking to them.
And in talking to the family, we decided, would it be easier if we brought you to the
big city to see us and we could do everything at the same time, examine you, we would see
all the family members at the same time.
And to me that sounded very overwhelming and I didn't think they would do that, but somehow
that was their preferred way of doing things.
They organized for them to come and they come.
And so we're able to do the chest x-ray.
We do an eye graph.
We examine the child and the sister who was also with sex at that time and was also a
con.
And so we see them in our little TV room in the hospital, like in the old part of the
hospital where there's no window and there's not really an examination bed.
And so Claire is, she's busy, she's climbing on the wall, she's playful, she's curious,
she's very, very chatty.
And sometimes it's like she doesn't have any symptoms.
No cough, no fever, no fatigue, no decreased appetite, nothing.
She's running around happy, nothing.
Her exam is totally normal.
Her sister is coughing a little bit, but that's it.
And then the chest x-ray comes back and it looks maybe a little bit viral.
We've all seen these chest x-ray with a bit of patchy, perihyal or thickening, not too
much, in any other child we would be like, ah, it's fine.
She gets an eye graph.
We get a result of the eye graph a few days later, but it's positive.
And then because she's been so hard to find her, the chest x-ray is not quite normal,
we decided to admit her for gastric washing on that day.
Met her and then do gastric washings.
And the parents are a little bit overwhelmed, like that's not what they were expecting.
And that's a lot more in investigations than what they thought.
But the TB nurse who saw them was like, you know, I'm not sure about them.
We better investigate them more.
We might not catch them again.
So anyway, gastric washings and the PCR on the gastric washing comes back positive and
the resistance pattern comes back indeterminate.
So we decided to admit her.
Further down the line, we found out that the culture was negative and that was the only
kind of clue that we had to diagnose it.
And we also did a chest x-ray on a sister.
Her sister had a completely normal exam, but she had a lafloral colonization and an error
bronchogram on her x-ray and a hyaluradenopathy.
She had a negative IGRA and her gastric washings were negative.
So you can see how the clues to diagnose are quite challenging.
Anyways, so we decide that we're going to treat them both as active because we know
that they had a really high risk contact.
You know, we have a positive IGRA, we have a positive PCR in one kid and abnormal chest
x-ray in the other kid.
So we decide to treat them.
Okay, we give them their first dose in hospital.
It goes well.
They go back home.
And then a couple of weeks pass.
And then we start getting calls every day by the TB workers in the community who are
giving them their directly observed therapy in the community because they're struggling
with Claire.
So they go to the house every day and then no one opens the door.
Everyone is sleeping.
The kids have a reversed sleep cycle.
They sleep all day.
Even when they get into the house, it's impossible to wake up.
They spend two hours at her house every day.
And when she does wake up, she bites the TB workers, she spits on them, she swears at
them.
And the workers are actually becoming afraid of her.
And so when that occurs, we try to mix the TB meds and all sorts of, you know, nice tasting
things.
We try to eat sandwiches, we try to eat slushies.
We try on a day where people were partially desperate, we tried Red Bull.
And that didn't work.
She kept on spitting and biting and everybody was getting worked up and traumatized through
all of this.
For her and the TB workers, it was just awful.
Then we tried to bring her to the clinic to give her the medicine there.
We tried to hold her down.
We tried to put NG tubes.
That wasn't working.
And we tried incentives, incentives for her family, incentives for her, like age appropriate
toys, sticker charts.
We tried to give her candy.
We tried to talk to the family to say, like, you know, how do you have anything that you
need in your house that we could help with?
The TB workers were bringing groceries every day to help with food insecurity.
We wrote letters for housing.
And then eventually we had meetings with several community members, meetings with elders, with
the holistic program in the community where we live.
Try to kind of have everyone on board to make this child take her treatment.
And everybody was very much on board, but the child would just not take her treatment.
And we worked at that for quite a few weeks.
Meanwhile, she remained well, she was clinically fine.
But people in her community and her parents and the TB workers were getting pretty worked
up because there were several bad outcomes at the same time from tuberculosis in that
same community.
So people were in the ICU, there was a death in a young person, not a child, but people
were quite afraid for her.
We needed to do something.
So in the end, we held another meeting with the family and elders in the community.
And we decided to bring the child to Saskatoon and work with the child life program to work
on medical play and trauma associated to health care that we could eventually give her her
treatment.
And so she worked with them every day for several weeks.
And after a few weeks, she was able to take her medicine after a few hours.
And eventually after a month, she was taking the medicine on her own.
So it took a very long time.
But then she went back to her community and finished her treatment.
We had to repeat her treatment entirely because we lost the time and we restarted and then
we couldn't trust that she had the right number of doses anyways.
But through that and the excellent work that child life and her parents and all the efforts
that were done, we were able to finally complete her treatment.
And so was her sister.
So her sister struggled less, but she was seeing less and it was also difficult for
her anyways.
And so when they both finished their treatment, we had a little celebration with cake and
we had identified something that they wanted for the end of their treatment.
So they both got an iPad and it was very lovely.
And everybody was so proud of what they've accomplished and the good things that everybody
had done through that.
But it was very difficult.
And it even raised some concerns for the TV program about trust building in the community.
We knew that there had been some bad outcome and there was potential danger in losing the
family and the community's trust.
And we had to navigate that very carefully.
And not too forcefully, right?
Because the circumstances in Canada is so linked to colonialism and racism and medical
trauma, et cetera.
So these are very sensitive areas to navigate.
Wow, that is very challenging, but I mean, definitely rewarding.
So like definitely Pat and your guys is back because that is impressive to go through all
of those challenges.
I mean, there was so many challenges with like diagnosing in this case, access to care,
just transportation in general, actually basic health needs that weren't being met, that
was probably also creating a huge challenge in this case.
And this is not uncommon for a lot of provinces or centers that are experiencing TV outbreaks
as well.
And so I think a lot of our listeners probably relate to that.
So in terms of, I mean, one thing I took from this was that you need to have a multidisciplinary
team.
Like that is huge.
Yeah, it is huge.
Yes.
We don't have a social worker in our program.
Yeah.
So that's what I mean, right?
It's like if you need a program to be running this efficiently, like this to me, I mean,
obviously I'm looking at it from an outside viewpoint.
I know the end outcome.
I'm sure it was like there's many more hurdles in between that we didn't even speak about
during the case.
But in general, I mean, just looking at, you know, without having multiple people involved
in this case, there would be a limited chance to run a program so efficiently.
You need to have, you know, just the morale to first of all, because it's very, it's almost
like difficult to continue pushing yourself to try to advocate that we need treatment,
you know, and we all talk about, you know, how the diagnosis is difficult.
And you know, all of us kind of hone in on that, that it's very difficult to diagnose.
But I mean, treatment, like, I mean, I personally, if I had to take a medication for like six
months or longer, I think it's challenging.
And now we're asking like children, you know, to do this for a long period of time.
So I think, I mean, a couple of things that maybe our programs need to also look into
is that as TB increases and pediatric TB is increasing, maybe we need to increase our
resources to make it more child friendly, too.
Right.
So I think you mentioned some good ways of, you know, hiding the medication into different
tasteful foods.
That's an approach that I think all pediatricians are used to doing, especially in our infectious
disease world, because not antibiotics also don't taste great.
A lot of them.
So yeah.
And so, but definitely, I think coming up with like having child life support rates,
when not every center would have that ability, right.
And so I think a lot of programs should likely reassess, you know, and have to reassess what
resources they have and like what resources they may need.
If we continue to see, obviously, this much pediatric TB and complicated pediatric TB,
where, you know, it's not just the complications around the actual diagnosis and using medication
that's like resistant, because I know an adult TB, a lot of times will face a lot of resistance
or even, you know, foreign born children that are coming into Canada and they have tuberculosis,
you see a lot of their resistance as a complication.
But in this case, I mean, it was already complicated enough to know that the sister didn't even
have some of the, you know, clinical findings, whether she's living in the house and she
has the symptoms.
And then she has these diagnostic tests that are not indicative of TB, right.
So wow, that's challenging.
So I guess one question I want to pose, and it is about the diagnosis, because I get asked
this question multiple times a day.
And so I think it's nice to address is the, I guess, the difference between so when do
we know like TST versus IGRA?
And like, what is our reliability?
And if somebody is a contact, like how the sister was in this case, but her IGRA was
negative, but she's a contact, I mean, in this case, you guys started her own treatment
and you prevented any long term complications in her.
Is that the approach that you would use in most children then?
Yes, the answer to this is complicated.
And I think as like the more I progress with learning about TB and doing TB work is one
needs to be comfortable navigating the gray.
Yeah, there is no black and white answers, especially in pediatric TB.
So the official answer is for IGRA and skin test, so skin test meant to TST is all equivalent,
right?
So we have good evidence to say that screening for kids older than five years old, IGRA is
equivalent to TST.
For kids who don't need serial testing, IGRA is appropriate.
The problem with IGRA is that it's often not available in smaller communities, smaller
centers, it's a very finicky lab to get.
We often don't have access to that other than in hospitals.
And then TST is always fine to do in everyone.
From two to five years old, there's a little bit of a gray zone where we think that IGRA
is probably fine, but we don't have the greatest evidence.
And under two, we also think it's probably working.
We have a little bit of evidence, I think it is coming, but we don't have hard evidence
to be able to say for sure, use an IGRA and TST.
In the end, oftentimes in kids where you really want to make sure, sometimes you might do
both and that might be helpful.
But the end of the story is an IGRA or a TST helps you identifying TB infection and not
TB disease.
And oftentimes, especially in kids, the smallest, the more often you will see this is that in
active disease, they'll have energy and their TST will be negative and their IGRA will be
negative.
It is reported as being 30 to 40% of cases of active TB, which is huge.
And so a negative screening test doesn't rule out in any way TB infection or TB disease.
Now you have to work with your risk factors and exposure and epi data to see how much
important, to decide how much importance you're going to put on a negative test.
And that's the great, the great patient comes handy.
So for them, these sisters, they had a clear epi link.
They were exposed to a four plus mere positive pulmonary case for extended periods of time.
Both of them had symptoms and we did have bacteriological confirmation for one of them.
So it all made sense despite screening tests in the older girls.
But in someone who doesn't have contact, no risk factors, no symptoms, no imaging, well,
you might ask yourself, why did you do the screening test first?
But the negative test doesn't, you know, might need more.
Right.
Okay.
No, that's fair.
Yeah.
So anybody who sees TB or manages TB or has, you know, been around, like even our pharmacists
who have been around anybody who's managing TB kind of knows that there's always this
gray zone.
And if the kind of the clinical picture is there, then it's probably more likely reliable
in that case.
Yeah.
And then you have that contact, right?
So yeah.
And I, that might be me being careful.
And I think everyone, you know, works differently depending on their experience and their comfort
level.
But especially if there's an epi link, I verge on the, on treating, other than, and especially
treating for latent when I'm not sure.
I either wait and observe if they're well, which we can totally do that, right?
TB will eventually declare itself or treat.
Yeah.
That's fair.
Okay.
So before we move on to the third case, I want to just touch on, you mentioned the stigma
around TB.
So are there resources or, you know, like as healthcare professionals, like for us,
like are there, I mean, we mentioned that we don't have a social worker on our team,
but in general, like, are there some resources that we can help families with the stigma?
And obviously, I mean, you know, they like, we can, what's something that we can lessen
the burden on them, because I know that could be very challenging, especially in some of
these communities that you're going to, and you're working in and have outbreaks.
I mean, it's very difficult for people to not, you know, find out or know what's going
on, right?
So is there any kind of guidance that you would give since you've had, you've had some
experience in some of these northern communities?
It's something that I find very difficult to navigate.
And it often comes to relationship building and trust building and forming relationships
with the entire community, knowing the place that you work in and knowing the TB workers
and the elders and finding out if possible, what is it that people are worried about,
goes a long way.
And the consistency in the people working in those specific community can also be very
helpful.
But, you know, again, that's easier said than done.
In the new Canadian TB guidelines that were just published in the spring, there is an
entire chapter that's dedicated to kind of cross-cultural care and working in communities
that have been traditionally stigmatized and marginalized, which is a really good resource
for a health care provider that I would encourage you to read.
But in terms of people living that life, you know, there's lots of people who have memories
of being in the sanatorium and being taken away from their family and their years and
all of that is very traumatizing and still very present in people's minds and lives.
And so addressing this slowly and gently, I think is helpful.
But also, and again, I feel this is almost cliche to say, you know, but again, addressing
the reasons why people found themselves in that place, right, it's because of, you know,
societal mistreatment over generation, living in poverty, unstable housing that's not been
updated and security and all of that weighs a lot more in people's minds.
And so addressing that will also help with trust building.
And it's so important to the work that we do.
Like we couldn't treat TB if we didn't have the resources to support that somewhat, even
though whatever we're doing is insufficient.
Yeah, well, that's a really good point.
Yeah, it's challenging.
I mean, it's something that's going to take a lot more years probably and a lot of support.
And I think having the resources that we have now, I mean, I think we're already definitely
better than we were a few years back.
And I think everything is moving in the right direction.
Yeah, I agree.
And I actually, I work with this wonderful TB nurse that is a mentor to me.
And she said, you know, I think people in the communities where there are currently
outbreaks and are potentially communities are isolated and traditionally stigmatized
by the rest of society.
People are doing a beautiful thing, seeking care and bringing their children to medical
attention and accepting the screening and participating in contact tracing.
They're working for their community and this is what is most helpful.
And showing this and putting light on this.
I think for my small, small, you know, ignorant perspective might help with decreasing the
stigma, you know, and putting power back into people.
Yeah, no, that's a fair point.
And really like commending like those that do come forward for screening and saying,
you know, that there were a case or they have symptoms, that type of thing, despite the
stigma.
So I think that's actually a very good point you bring up.
These good outcomes of success stories of patients who finished their treatments are
helpful.
We did notice even after that case that people would come to the clinic worried about TB,
being like my kids were in contact with X person and X person, should I be worried and
asking more about it?
And this is what we're hoping for, you know, and I think that's an extraordinary thing.
Yeah.
And I love the idea of like celebrating at the end.
That was great.
I love the parties.
That's awesome.
That's great.
All right.
So why don't we move on to the third and the final case for today?
And this has just been like already it's like so informational.
So I can't even thank you more like, you know, enough for being on the podcast today.
It's great.
Thank you so much.
I mean, I could talk about this all night, but I don't have time.
Okay.
So let's do the third case.
So we have a 12 year old girl who we will call Lindsay and Lindsay presented to a walking
clinic in the fall.
And her presenting concern was that she had a worsening back pain since the previous summer,
but not much else in terms of other symptomatology.
She didn't really have any red flags at that time.
She didn't have any fever, weight loss, et cetera.
The pain wasn't waking her up at night.
And she came to this walking clinic in a medium sized city where TB, I imagine, wasn't necessarily
top of mind when she was seen.
You know, a teenager that comes with back pain, we see this every day, right?
But in any case, there was a spine x-ray that was done at her first presentation.
And then that showed, I wish I could show you the x-ray.
It showed a small lytic lesion at T8.
And the report says MRI is recommended, follow up recommended.
And then there's a CT that's requested by the physician who saw her at the walking clinic,
who's not like a clinic that knows her or will follow her up or anyways, but they requested
the CT.
And then not much happens for quite a few months.
And eventually her parents are like, oh, right, like she still has back pain.
There was supposed to be a CT.
What's happening with that?
They found the clinic and they discovered that the requisition was lost.
That's three months post her initial presentation.
And of course, in interim, her back pain has worsened.
She's missed weeks of school and then she developed progressive leg weakness.
She's not able to get up on her own.
She falls a lot.
And then quite worrisomely, over the last week, she noticed that she's been more constipated
than usual and she's been having difficulty passing her urine.
Anyways, so there's a urgent CT that's organized for that same day.
Oh, she also developed fevers, nights fits and has lost 10 pounds since she was last
year.
So there you go.
And then the CT shows that lytic lesion at T8 that's grown is destructive.
There's destruction of the vertebral bodies and posterior elements.
And then the report says these findings are very concerning for Ewing sarcoma or lymphoma.
Possibly a CRMO should be explored.
Infection is less likely.
And I think we're actually involved in this case.
You probably remember that.
So after that CT, that same day, she's sent from that mid-level city to a tertiary care
center that same day.
And she's admitted under ortho and oncology is consulted.
And she has a workup that's initiated for sarcoma with a full body PET CT and MRI of
her spine.
Both ortho and oncology reports very likely malignancy.
The MRI report, PET CT report also say that.
And there's an order that's booked the next day for decompression of her spine.
And then on the PET CT, they're described that lytic lesion from the CT, but there's
also another lesion at T5 that's suspicious for Mets.
And she has a small parol effusion with a small parol nodule that they say is also suspicious
for Mets.
Her lung parenchyma is normal.
And the rest of her PET CT is normal.
And then we think about consulting Dr. Purwil for rule out infection before her OR.
And Dr. Purwil, who's seen crazier things, says, you know, make sure you send samples
for TV in addition to all of these other things.
In doing her very thorough history, like these ID likes to do, I think you found out that
she had ties to one of the communities where there was outbreak.
She actually went back and forth from this community and spent a lot of time there even
before her symptoms started.
She even lived in that community for years before she went to high school.
Anyways, that's in the background.
While she's going to the OR, the decompress is fine.
It's a very long surgery.
There's two surgeons involved.
It was very, very complex.
But you resect the mass.
And then they send the sample for PATH.
And on the same day, we get a preliminary report, no malignant cells.
There's granulomethase, inflammatory infiltrates, and some necrosis in the sample, which is
non-caziating, but nonetheless, some necrosis.
And then we fast-tracked the TB PCR on that sample, which came back positive.
And that's when the TB program got involved.
And eventually, her eye graph came back positive.
And the sample from her OR, the cultured brew, MTB, which was pen-sensitive.
So she was treated like disseminated TB, the pleura and bone.
She was put on 9-ounce of TB treatment with the traditional Ripe Therapy.
And she had an excellent outcome.
If you look at her CT images, false treatment, it's fully evolved.
There's no sequelae at all.
But most importantly, she's walking.
And she doesn't have any neurological sequelae from her bony osteomyelitis tuberculosis.
So again, I should pull the lesson from this case, are almost cliche and so classic, which
in tuberculosis, in children, early identification is so, so, so important to avoid dramatic
and horrible outcomes where she could have potentially been paralyzed, right?
Yeah, exactly.
Or have further dissemination.
And we want to avoid deaths and horrible disability in everyone, but particularly in children.
But also, often, when there is a mass in the picture, the malignancy will be top of mind.
And people will not necessarily think about including TB in their differential unless
there is clear causes, clear links to epi.
You did have, but they were a little bit difficult to find.
Yeah, yeah, no, for sure.
And I do remember this case being challenging in the sense that, I mean, most of the time,
you know, and I always teach my learners this too, is that it's really, really, really difficult
when you're called and somebody says, oh, this is a mass, you know, like, because mass
in everybody's mind, you know, tunnel visions you to malignancy.
Especially when all of the reports and all of the subspecialists kind of grasp that and
say, yes, it fits, etc, etc.
Exactly.
So I think like in this case, I mean, like any other case, I always tell learners is
like, you have to step back and remember that you go in with a clean slate, you know, take
your history, find out information and getting collateral information, especially like teenage
patient, teenager patients, I've noticed is like really important because sometimes they
can't remember, I mean, life is changing, right?
Like things are happening all the time.
You know, everything's a blur.
And so it's, I think, really important to be asking parents and, you know, whoever else
is in close contact with the family, that type of thing.
So I'm really not getting tunnel visioned and it's it's so difficult, though, because
I mean, especially for consultants, because you're told here's the clinical question.
Can you help us like an ID is a little bit different because every video is can you rule
out infectious disease, you know, I wish there was like a list of 10 diseases that I could
rule out for everybody.
But, you know, but in the end of the day, it's, it's our job, right?
Like, just like how you're you're a detective in TV world, I'm like a detective in the infectious
disease world, right?
So like, I have to put the pieces together and always remembering that the story has
to fit, right?
And if there's something off about the story, like the age group or the presentation, then
always reconsidering, like, maybe this isn't the diagnosis, and maybe I should think, you
know, maybe there's other things.
And that's why we do all these tests, right, so that we can actually let me most of the
time, it's to rule out certain diseases, you know, and like, some of the times they rule
them in, which is great.
And and, I mean, knowing that the utility of like, we're very lucky, because we have
a lab that can do, you know, PCR based tests for us quite quickly on kind of requests,
even I think that I remember this case being on a weekend.
So it was a Friday afternoon, and like Saturday morning, we had the PCR result back, right?
So I think like, we're fortunate that we're in a center that we're able to do that.
And some centers may not have the capacity to do that.
But just remembering that if you have, you know, quicker diagnosis, and we knew that
going into this, we're going to get a good tissue sample.
So tissue is ideal, right for sampling.
So whenever in my world, if a tissue is positive or something, I mean, the yield is there.
Right.
So we can send it off.
And, and we always talk about in guidelines, like if it's fluid and for even sputum, and
there's less than, you know, a small amount like less than a mil, we always make sure
that culture is sent over PCR molecular based testing, as per our guidelines, which is very
accurate to do because we should be doing that so that we can actually definitively
diagnose and then also follow the resistance patterns and sensitivities.
But in cases where you know there's going to be an apple amount of tissue and you need
a rapid or apple amount of specimen, you need a rapid diagnostic test to kind of help you
rule in, I think PCR molecular based testing is definitely very helpful.
So it was for this case, at least for me.
So absolutely.
Yes.
And tissue and TB is always the best to yield.
All the other samples are, you know, notably not very good.
And so a negative sample doesn't necessarily mean anything as you know, of course.
And then for the PCR, what is interesting is that it's not validated for many types
of samples.
And so often, again, if it's negative, you know, one has to remember that it doesn't
totally rule it out.
But when it's positive, then that definitely will give you a lot of clues towards your
diagnosis.
So where you can do a gene experts sample, you can use the same machine to do different
samples.
And I know that some remote communities have gene experts for influenza, et cetera.
And I believe you can still and this is like, you know, non validated.
But in a pinch, you can use this machine to test like a student sample, a gastric washing
sample for a gene.
Okay, that's good to know.
I mean, especially like, you know, in a situation where you don't have much for resources or
you can't transport the patient to a bigger center.
Right.
So yeah, often big obstacles.
Yeah.
But in terms of malignancies and TB, those are often like you said, right, there is a
map.
So people look at me to rule out malignancies, right?
Because this is also what's going to kill people.
TB and malignancy go hand in hand, you know, like malignancies.
TB is often in the differential and vice versa.
But it can also happen together.
Right.
You have seen this people with, you know, classic presentation of TB adenitis.
But then you do a biopsy and you do find out that they have a lymphoma.
And so you need to be careful about not missing one when the other is present, but also making
sure that people don't have both things.
Yeah, no, that's actually a really good point.
Right.
And so a lot of these like diseases that are mimickers of one another.
Right.
And we had a classic always talk about these indolent presentation, that type of thing.
So the workup has to be extensive.
But yeah, keeping a broad differential.
Right.
That's what we that's what we practice.
So I think that's the end of the day, always remembering that there could be multiple things
going on.
And I think if you come up with a broad differential to begin with, it's easier to manage these
cases.
Wow.
So super interesting.
So we went through kind of the social concerns of managing TB.
We talked a lot about like, you know, access to care and complicated cases in terms of,
you know, just clinical presentations and contact tracing.
And then another case where, you know, diagnosis sometimes is so difficult.
And it's missed at times, and really keeping that in mind that some presentations can mimic
TB.
And if it is endemic, or if you're any suspicion, really getting a thorough history and really
knowing, I think, which communities in your provinces have higher TB cases and, you know,
keeping in touch with public health.
And I think for some physicians, a little bit easier, like I work daily with public
health, so they're always hearing from me.
And so I think it's similar to like a TB program, you guys will be in close touch.
So I think like encouraging other physicians, you know, even if you're out in the community
practicing somewhere, it's okay to call the medical officer of health or, you know, reach
out to your TB program and see if this is a community that maybe somebody is listed
as a contact, because that might just guide you to the right direction and prevent any
type of complication that we just talked about.
So I was actually going to bring this up.
So in Saskatchewan, I'm not sure how it works in other provinces, but I imagine it's similar.
You know, there's a TB physician on call 24 seven.
And as with any other consultants, it's totally okay to phone the TB physician with a question,
like you're not sure.
Do you think about TB in this specific case or not?
And if so, what kind of investigation should you do?
And that's why we're here, right?
And we're able to see, oh, is this person part of an ongoing contact trace?
Or maybe they were under our radar, we tried to reach them.
And so it's useful for everyone, including the TB program to receive these, these phone
calls.
And I would say with kids, if you're not sure, it's always urgent.
If TB pops in the back of your subconscious, call the TB physician.
Yeah, that is great advice.
Yes.
Because sometimes, I mean, especially with even pulmonary TB, some is difficult because
a lot of these patients are on like weeks of antibiotics first, right?
There's like this non-improving pneumonia, which then ends up sometimes being because
it doesn't really always have to present cavitary originally.
And so, so I think it can be really, really challenging, but always keep in the mind in
the back of the mind, you know, if there is any suspicion, it's better to just call and
use your resources.
Absolutely.
Even if you don't have any confirmation of anything and it's just a question, it's always
fine.
Yeah.
Well, that's fantastic.
Thank you so much, Dr. Brandemeyer.
That was like, honestly, it's just so refreshing to go through some cases because now all of
us are always thinking about different diseases and different conditions, especially living
in a province where it is endemic to TB.
A lot of our listeners, you know, they've reached out and they want to talk about it.
We know that there's TB outbreak areas here.
And so we've gotten a lot of questions regarding it.
And so I think this combined with the new guidelines is a really, really, really great
resource.
I think it's I think all learners, all physicians, you know, especially within Canada, where
we are seeing an uptick in our cases, we should all be familiar with this.
So I want to thank you for coming on the podcast.
And it was a fantastic episode and we look forward to having you back again for future
games.
Thank you so much for having me.
I was so honoured to be here.
Thank you so much.
Thanks.
Thank you, Dr. Purwall, and thank you, Dr. Brynne-Moore, for joining us.
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