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Tuberculosis

Introduction:

Tuberculosis (TB) is a bacterial disease that mainly affects the lungs. It is caused by the bacteria Mycobacteria tuberculosis and is spread through airborne droplets from an infected person. Before the discovery of certain antibiotic drugs in the 1940s, TB was the leading cause of death in the United States. Even though TB is not as common as it once was in the U.S., there has been a resurgence in recent years due to HIV, AIDS, and the spread of drug-resistant forms of TB. It is still a major health problem throughout the world, especially in poor countries. Up to one third of the world's population may be infected with TB, though the infection may not be active.



Signs and Symptoms:

If you have been exposed to TB, you may be infected but have no symptoms and not be contagious. Between 20 - 30% of people exposed to a person with active TB become infected. For that reason, doctors usually distinguish between infection (or a positive TB test) and an active infection. After you are infected, your immune system will attack the bacteria. Your body may kill all the bacteria, the bacteria may remain in your body but not cause an active infection, or you may develop the disease. TB can affect other areas of your body outside of the lungs, but lung infection is most common. Typically, TB bacteria that grow in the lungs may cause:

  • Mild fever
  • Headache
  • Chills
  • Night sweats
  • Fatigue
  • Loss of appetite, weight loss
  • Cough, with or without mucus and pus
  • Coughing up blood
  • Chest pain from inflammation in the lungs
  • Difficulty breathing
  • Swollen glands
  • Sore throat


What Causes It?:

Mycobacterium tuberculosis causes most cases of TB. The disease is spread from one person to another through airborne bacteria. However, it isn't easy to catch TB. You need consistent exposure to the contagious person for a long time. For that reason, you're more likely to catch TB from a relative than a stranger. Typically, a person with TB in the lungs or the throat coughs or sneezes. Others nearby then breathe in the bacteria. When a person breathes in TB bacteria, the bacteria can settle into the lungs and begin to grow.



Who's Most At Risk?:

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

  • Working in the health care profession or as an embalmer
  • Being born in or spending time in a country where TB is common (for instance, most countries in Latin America and the Caribbean, Africa, and Asia, excluding Japan)
  • Living in overcrowded, unsanitary settings where TB is common (for example, homeless shelters, migrant farm camps, prisons and jails, and some nursing homes or long-term care facilities)
  • Having HIV or AIDS. As HIV attacks the immune system, existing TB infections may become active, or it may make it easier for someone to catch TB. The TB bacteria, in turn, cause the HIV virus to replicate more quickly.
  • Using medications that suppress the immune system (Remicade, Enbrel)
  • Smoking
  • Alcoholism
  • Organ transplantation
  • Having no or inadequate access to health care
  • Having diabetes (the risk of contracting TB is 2-3 times higher among people who have diabetes compared to people who don't have diabetes)
  • Having a rheumatic disease


What to Expect at Your Provider's Office:

If your doctor suspects a TB infection, you will need a skin test. A positive reaction to the test means you are likely infected with TB, although false positive and false negative results are possible. To confirm the diagnosis and determine if the infection is active, you may need to have samples taken of your sputum (mucus and other material coughed up from the lungs) or stomach fluid to check for TB bacteria, as well as a chest x-ray.



Treatment Options:

Prevention

TB is difficult to treat (see "Drug Therapies") so prevention is important. Prevention of TB begins with rapid diagnosis and treatment to avoid spread to noninfected persons. In countries where TB is common, a vaccine called BCG may be administered. However, the vaccine causes a false positive on the skin test and is not very effective in adults, so it's rarely given in the U.S.

If you are at risk, you should be tested for TB every 6 months. If you test positive but have no signs of active infection, you may be given the medication isoniazid to prevent an active infection.

The most important way to keep TB from spreading is for infected people to take their medications exactly as prescribed. If you do not take all of your medications, you run the risk of developing multidrug resistant TB, which you can then spread to others. Drug resistant TB is a major health problem in the U.S. and around the world. If you have TB, keeping all of your clinic appointments is essential so that your doctor can check for side effects from the drugs and evaluate the effectiveness of the treatment. If you are sick enough with TB to go to a hospital, you may be put in a special room with air vents that keep the TB bacteria from spreading. You will most likely be prevented from leaving your room while you are contagious (about 2 weeks after treatment begins). People who come into the room will wear special face masks to protect themselves from TB bacteria and to prevent the spread of TB bacteria to others.

Treatment Plan

If your doctor suspects TB, treatment may begin before all lab tests return. This may include more than one anti-TB drug. Emergency treatment may be necessary if, for example, you are coughing up blood.

Drug Therapies

TB bacteria die very slowly. It takes 6 months to a year for the medicine to destroy all of the TB bacteria -- longer for multidrug resistant TB. If you have TB, you will need to take several different drugs. You will be tested first for drug resistance to determine the most effective combination of drugs to prevent the bacteria from becoming resistant to the drugs. The most common drugs used to fight TB are:

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

Complementary and Alternative Therapies

TB should never be treated with alternative therapies alone. To cure the disease, and to avoid spreading it to other people, you must be treated with prescription medications. Some CAM treatments may be useful as supportive therapies.

Even if complementary therapies are used, conventional prescription drugs must be taken exactly as directed. Complementary therapies do not allow patients to get by with less medicine or to skip doses. Skipping doses is a major cause of the development of drug resistant strains and greater spread of the disease.

Nutrition

Following these nutritional tips may help reduce risks and symptoms:

  • Eliminate all suspected food allergens, including dairy (milk, cheese, eggs, and ice cream), wheat (gluten), soy, corn, preservatives, and chemical food additives. Your health care provider may want to test you for food allergies.
  • Eat foods high in B-vitamins and iron, such as whole grains (if no allergy), dark leafy greens (such as spinach and kale), and sea vegetables.
  • Eat antioxidant foods, including fruits (such as blueberries, cherries, and tomatoes), and vegetables (such as squash and bell pepper).
  • Avoid refined foods, such as white breads, pastas, and sugar.
  • Eat fewer red meats and more lean meats, cold water fish, tofu (soy, if no allergy), or beans for protein.
  • Use healthy cooking oils, such as olive oil or vegetable oil.
  • Reduce or eliminate trans-fatty acids, found in commercially baked goods such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
  • Avoid coffee and other stimulants, alcohol, and tobacco.

You may address nutritional deficiencies with the following supplements:

  • A multivitamin daily, containing the antioxidant vitamins A, C, E, D, the B-complex vitamins, and trace minerals such as magnesium, calcium, zinc, and selenium.
  • B-complex vitamin, 1 tablet daily.
  • Vitamin C, 1 - 6 gm daily, as an antioxidant. Vitamin C may interfere with vitamin B12, so take doses at least 2 hours apart. Lower the dose if diarrhea develops.
  • Vitamin D, 200 - 400 IU daily. Several studies show that low levels of vitamin D may explain why some ethnic groups tend to be more susceptible to TB. This early research is very promising, although it isn't yet known whether vitamin D can help prevent or treat TB. Many nutritionally-minded physicians recommend higher doses of vitamin D. Talk to your doctor about taking supplemental vitamin D to establish the proper dose for you.
  • N-Acetyl Cysteine, 600mg, 2 capsules 3 times daily, as a powerful antioxidant and to breakdown accumulated mucous. N-Acetyl Cysteine can interact with nitroglycerin.
  • Probiotic supplement (containing Lactobacillus acidophilus and other beneficial bacteria), 5 - 10 billion CFUs (colony forming units) a day, for maintenance of gastrointestinal and immune health. Some probiotic supplements may need refrigeration. Some doctors are concerned about giving probiotics to severely immune-compromised patietns. Speak with your physician.
  • Alpha-lipoic acid, 25 - 50 mg twice daily, for antioxidant support. People who are alcoholics and those who have nutritional deficiencies should be cautious when taking Alpha-llipoic acid. Alpha-lipoic acid may contribute to Thiamine (B1) deficiency and thus may cause serious side effects. There is some concern that Alpha-lipoic acid may interfere with certain cancer medications (chemotherapy). Speak with your physician.
  • Resveratrol (from red wine), 50 - 200 mg daily, for antioxidant effects.
  • Beta-sitosterol, 60 mg daily. Beta-sitosterol, a compound in some plants, may be helpful when given along with conventional medication, although results from one study were uncertain.

Animal studies suggest that TB may be more severe in persons with diets rich in omega-3 essential fatty acids. These studies are not comprehensive, and it's not clear whether there is a similar effect in humans. Until researchers know more, however, it may be wise to avoid omega-3 supplements (such as fish oil) if you have or are at risk for TB.

Herbs

Herbs are generally available as standardized, dried extracts (pills, capsules, or tablets), teas, or tinctures/liquid extracts (alcohol extraction, unless otherwise noted). Mix liquid extracts with favorite beverage. Dose for teas is 1 - 2 heaping teaspoonfuls/cup water steeped for 10 - 15 minutes (roots need longer). Although herbs should never be used alone to treat TB, some herbs may be helpful along with conventional medical treatment. 

  • Aged Garlic (Allium sativum) extract, 600 - 1200 mg daily, for antibacterial and immune-stimulating properties. Use garlic supplements only under the supervision of a health care provider if you take blood-thinning medications, such as warfarin (Coumadin). Garlic may interfere with a number of medications, including, but not limited to, medications used to treat HIV and birth control pills.
  • Astragalus (Astragalus membranaceus) standardized extract, 250 - 500 mg 3 - 4 times daily. A preliminary study indicates that astragalus may be helpful in treating TB. Astragalus may interfere with some medications, including lithium. Speak with your physician.
  • Rhodiola (Rhodiola rosea) standardized extract, 150 - 300mg 1 - 3 times daily, for immune support. Rhodiola is an "adaptogen" and helps the body adapt to stress. High doses of Rhodiola can have blood pressure lowering and blood-thinning effects, and may increase the effect of blood-thinning medications, such as warfarin (Coumadin) and aspirin. Speak with your physician.

Homeopathy

Few studies have examined the effectiveness of specific homeopathic remedies. Professional homeopaths, however, may recommend one or more of the following treatments for tuberculosis based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type -- your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

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

Acupuncture

Acupuncture can help strengthen your immune system response, as well as support your lung function.



Prognosis/Possible Complications:

A full course of medication can cure TB in people who do not have a multidrug resistant strain. It can be fatal in the elderly, in those who have TB that has spread to locations other than the lungs including miliary TB (which spreads through the bloodstream affecting many organ systems), in those with multidrug resistant strains of TB, or in those with HIV.

Possible complications of TB include:

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


Following Up:

U.S. public health policy requires health care providers to report cases of TB and to treat or quarantine all patients. Most patients may remain at home, but all should be kept from any new contacts for at least 2 weeks after treatment begins. The elderly and those who are acutely ill or have multidrug resistant TB should be hospitalized for the first few weeks of treatment.

It is essential to take all TB medication exactly as prescribed in order to cure TB and prevent drug resistance. Sputum samples are collected and tested monthly. If tests are still positive after 3 months of treatment, the infection is considered multidrug resistant and a change in medications is in order.



Special Considerations:
  • Infants born to mothers with infectious TB should be separated from the mother until she is no longer contagious. The infant should then be tested for TB at 4 - 6 weeks and 3 - 4 months.
  • Women can be treated for TB during pregnancy and while breastfeeding but should avoid streptomycin and pyrazinamide.

Since effective treatment of TB depends on taking multiple antibiotic drugs for an extended period of time, it is essential that you consult with your health care provider before using complementary or alternative therapies, including taking herbs and vitamin supplements.



Supporting Research:

Abubakar I et al. Controversies and unresolved issues in tuberculosis prevention and control: a low-burden-country perspective. J Infect Dis. 2012;205 Suppl 2:S293-300.

Bafica A, Scanga CA, Serhan C, Machado F, et al. Host control of Mycobacterium tuberculosis is regulated by 5-lipoxygenase–dependent lipoxin production. J Clin Invest. 2005 June 1; 115(6): 1601–1606.

Baker MA, Lin HH, Chang HY, Murray MB. The risk of tuberculosis disease among persons with diabetes mellitis: a prospective cohort study. Clin Infect Dis. 2012;54(6):818-25.

Bastian I, Colebunders R. Treatment and prevention of multidrug-resistant tuberculosis. Drugs. 1999;58(4):633-661.

Ben m'rad M, Gherissi D, Mouthon L, Salmon-Ceron D. Tuberculosis risk among patients with systemic diseases. Presse Med. 2009;38(2):274-90.

Bope: Conn's Current Therapy 2012, 1st ed. Philadelphia, PA: Saunders. 2011.

Bornman L, et al. Vitamin D receptor polymorphisms and susceptibility to tuberculosis in West Africa: a case-control and family study J Infect Dis. 2004 Nov 1;190(9):1631-41.

Getahun H, sculier D, Sismanidis C, Grzemska M, Raviglione M. Prevention, diagnosis, and treatment of tuberculosis in children and mothers: evidence for action for maternal, neonatal, and child health services. J Infect Dis. 2012;205 Suppl 2:S216-27.

Goldman: Goldman's Cecil Medicine, 24th ed. Philadelphia, PA: Saunders. 2011.

Karp CL, Andrea M. Cooper AM. An oily, sustained counter-regulatory response to TB. J Clin Invest. 2005 June 1; 115(6): 1473–1476.

Kliiman K, Altraja A. Predictors of extensively drug-resistant pulmonary tuberculosis. Ann Intern Med. 2009;150(11):766-75.

Liu PT, Stenger S, Li H, Wenzel L, Tan BH, et al. Toll-like receptor triggering of a vitamin D-mediated human antimicrobial response. Science. 2006 March 24; 311:1770-1773.

Mason: Murray and Nadel's Textbook of Respiratory Medicine, 5th ed. Philadelphia, PA: Saunders. 2010.

Newton SM, Lau C, Wright CW. A review of antimycobacterial natural products. PhytotherRes. 2000;14(5):303-322.

Niu HR, Lai ZH, Yuan L. Observation on effect of supplementary treatment by Astragalus injection in treating senile pulmonary tuberculosis patients. Zhongguo Zhong Xi Yi Jie He Za Zhi. 2001 May;21(5):349-50.

Schlossberg D. Acute Tuberculosis. Infectious Disease Clinics of North America. 2010;24(1).

Uhlin M, Andersson J, Zumla A, Maeurer M. Adjunct immunotherapies for tuberculosis. J Infect Dis. 2012; 205 Suppl 2:S325-34.

Wilkinson D. Drugs for preventing tuberculosis in HIV infected persons. Cochrane Database Syst Rev 2000;No. 2:CD000171.

Wilkinson RJ, Llewelyn M, Toossi Z, et al. Influence of vitamin D deficiency and vitamin D receptor polymorphisms on tuberculosis among Gujarati Asians in west London: a case-control study. Lancet. 2000;355(9204):618-621.

Wright A, et al. Epidemiology of antituberculosis drug resistance 2002 - 07: an updated analysis of the Global Project on Anti-Tuberculosis Drug Resistance Surveillance. Lancet. 2009;373(9678):1861-73.

Zumla A et al. Drug-resistant tuberculosis -- current dilemmas, unanswered questions, challenges, and priority needs. J Infect Dis. 2012;205 Suppl 2:S228-40.




Review Date: 12/28/2012
Reviewed By: Steven D. Ehrlich, NMD, Solutions Acupuncture, a private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare.

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