Katherine Poehlmann, Ph.D., describes the immunologic effects of acute and reactivated (latent) forms of tuberculosis (TB) and its global prevalence. She details the methods for TB testing, the typical disease course, and its potential for causing chronic disease, such as Tuberculous arthritis. Katherine also outlines the long-term antibiotic therapies normally used to treat TB and supplemental adjuncts to prevent its occurrence or to promote its healing.
Tuberculosis Leading to Tuberculous Arthritis
Epidemics play a role in human evolution by inducing genetic changes that survivors pass on to their descendants in the form of resistance to re-infection. However, this resistance makes survivors’ immune systems reactive or allergic to other pathogens. This new immune reactivity may be called an autoimmune disease. In 2005, a scientist found a link between tuberculosis (TB) and rheumatoid arthritis (RA).
TB in the joints, called Articular TB or Tuberculous arthritis, progressively destroys the joints at the hips, knees, feet, elbows, wrists, and shoulders. The bacteria colonize in the synovial tissue and grow slowly over and through the cartilage into the underlying bone, which decalcifies. In the spine, the disease starts in a disc. Spinal TB, if left untreated, can spread from one vertebra to the next, weakening the bones and destroying the cushioning discs between them. In severe cases, the spine can collapse and pinch the spinal cord, causing paralysis of the lower body.
When we think of tuberculosis we may envision immigrants coming through Ellis Island at the end of the 19th century. Entry was subject to health screening and treatment for those having communicable diseases, including active TB. Tuberculosis was rare for decades in the U.S., until a TB epidemic in the late 1980s convinced the CDC that better screening methods and improved treatments were required.
According to CDC 2015 statistics, TB occurs at a rate of 3 cases per 100,000 in the U.S., with 27 states and the District of Columbia reporting an increase in TB cases from 2014. Case rates among foreign-born persons are five times greater. The CDC plans to strengthen existing measures for high risk groups, including Asians and native Hawaiians (18 cases per 100,000)
A third of the world’s population may be infected with tuberculosis. This disease, known since ancient times, is one of the top ten causes of death around the globe, with most of the 1.8 million deaths per year (worsened by HIV) occurring in developing countries.
TB is caused by Mycobacterium tuberculosis that is transmitted primarily via respiration. Infection occurs in the lungs, but the bacteria can spread through the blood to seed any organ. A person with latent TB may harbor inactive bacteria and show no symptoms. In approximately 5 to 10% of latently-infected persons, the infection will reactivate and cause active TB when the immune system is dysfunctional. Active TB can occur any time after the initial infection – from a few weeks to years later – and then it can spread to others.
In response to infection with M. tuberculosis, the immune system mounts a robust response by forming nodules that wall off and isolate the infection, but this action does not eliminate it. In most cases, the well-nourished host response may hold off active disease for a lifetime. However, the immune response may fail in many ways, allowing the infection to reactivate and develop into the contagious form of the disease. In a TB secondary (reactivation) infection, walled-off bacilli inside old nodules escape and the ensuing hypersensitivity reaction can destroy the lungs. Patients suffer a chronic (often bloody) cough (consumption). Without proper treatment and good nutrition, especially vitamin C, the disease is fatal.
An estimated 2 billion people worldwide (and many domesticated animals) have latent TB. With increased air travel, interaction with developing countries, and lack of health screening for persons crossing borders, everyone should be alert to signs of TB and seek medical attention if symptoms appear or they have been in contact with suspected infected persons or livestock.
The following are the most common symptoms of active TB. Symptoms will vary among individuals:
- Persistent cough, especially with blood in the sputum
- Chest pain, shortness of breath
- Loss of appetite, unintended weight loss
- Poor growth in children
- Fever, chills or night sweats
A variety of tests can identify TB. The skin test may yield false-negative results in certain groups: the very young, the elderly, those afflicted with AIDS, and people recently infected with TB whose immune systems have not yet reacted to the bacteria. Blood tests are more reliable. X-rays are useful imaging tests for those who have active TB and the body has formed nodules in the lungs. Sputum samples can be tested for drug-resistant TB strains.
Long term (six to nine months) antibiotics are the standard treatment for active and dormant (test positive) TB. These include: Isoniazid, Rifampin (Rifadin, Rimactane), Ethambutol (Myambutol), and Pyrazinamide.
For those with drug-resistant TB, fluoroquinolones (FQs) and injectable medications may be prescribed for 20 to 30 months. FQs are commonly prescribed for respiratory and urinary tract infections. These drugs include ciprofloxacin (Cipro), gemifloxacin (Factive), levofloxacin (Levaquin), moxifloxacin (Avelox), norfloxacin (Noroxin), and ofloxacin (Floxin). More than 23 million FQ prescriptions were written in 2011.
Be aware that severe and disabling adverse effects may occur with FQs, especially among those taking corticosteroids or who have pre-existing joint or tendon inflammation problems. Side effects can also involve the muscles and serious nerve damage (peripheral neuropathy).
Those taking certain medications and/or are afflicted with particular health conditions increase their risk of TB infection. These include:
- Immunosuppressive viruses/co-infections like HIV, AIDS, HHV, HSV
- Respiratory: COPD, Strep/Mycoplasma/Chlamydia pneumonias
- Severe kidney disease
- Certain cancers
- Cancer chemotherapy
- Drugs to prevent rejection of transplanted organs
- Immune suppressive drugs used to treat RA*, Crohn’s disease, and psoriasis
- Malnutrition, especially vitamin C deficiency
- Allergies and toxins that deplete antioxidant vitamins
- Very young or advanced age
*Tumor Necrosis Factor-alpha (TNF-a) blockers such as Remicade, Enbrel, Humira
The Best Defense Against TB
It is a cruel twist of fate that surviving an epidemic predisposes the immune system to be vulnerable to an equally destructive infection. A robust immune system is the body’s best defense against infectious organisms of all kinds. Increased intake of vitamin C is one of the most beneficial actions one can take.
Vitamin C (oral, IV, liposomal) will both moderate Jarisch-Herxheimer inflammation and increase antibiotic effectiveness in killing the TB bacteria. Consult an experienced Orthomolecular medicine practitioner. See Chapter 14 in Dr. Stone’s book The Healing Factor. See suggestions by Dr. Cathcart for vitamin C dosage to combat infections.
RBF Commentary: Rheumatic patients who are immune-suppressed with conventionally-used medications have an increased risk for contracting TB. For this reason, screening should occur in advance of, and at intervals during, treatment with any immune-suppressant medication. The risk of contracting TB is greatly reduced when only using antibiotic therapy to treat rheumatic diseases, but the antimicrobials employed need to be tailored for patients with concomitant TB due to infection strain susceptibilities, as described by Katherine in this blog article.