Prognosis for TB Traveler: Isolation, Surgery, Uncertainty

May 31, 2007— -- Had 31-year-old Atlanta lawyer Andrew Speaker walked into Denver's National Jewish Medical and Research Center unaccompanied, it is unlikely anyone would have known that he had a communicable disease -- one that doctors estimate kills one out of every two people it infects.

However, he did not walk in alone.

Surrounded by health workers and security personnel wearing masks, a symptom-free Speaker entered a room Thursday morning where he will likely spend weeks, or even months, fighting a potentially deadly tuberculosis infection that drugs have so far failed to eliminate.

Now doctors say that Speaker will likely face treatment with an unorthodox battery of medicines -- and possibly even surgery -- in his battle against his infection.

A Last Shot for Drugs

In an interview on ABC's "Healthy Life" Thursday, Dr. Neil Schluger, professor of epidemiology at Columbia University School of Medicine in New York, said that most of the time, antibiotic therapy is enough to rein in and eventually eliminate tuberculosis infections.

"The vast majority of these cases -- 98 percent or more -- can be treated with medications alone," he said.

But he said in the case of extremely drug-resistant TB, antibiotics may not be available to treat the infection.

Thursday, doctors at National Jewish planned to try two more antibiotics against the extensively drug-resistant disease -- one oral, the other an intravenous injection.

Dr. Henry Boom, director of the tuberculosis research unit at Case Western Reserve University School of Medicine, said such a "cocktail" is a common strategy for a resistant case like Speaker's.

"What's done in this situation is that you look at the drug-resistance pattern and try to come up with a cocktail of at least two or three drugs that have potential for treatment," he said.

Three more antibiotics may be on the way for Speaker this week, and doctors will continue to scrutinize an isolated sample of bacterium taken from Speaker's body to see if anything in the current arsenal of medicines can kill it.

"For people who have multidrug resistant or extensively drug resistant tuberculosis, you do as many tests that you can do on the isolate," said Dr. Christopher Ohl, associate professor of infectious diseases at the Wake Forest University School of Medicine and chairman of the North Carolina Medical Advisory Committee for Tuberculosis.

If the drugs work on the isolated sample, Ohl said, they may also work on the infection in the body.

But the antibiotics that will likely be used in Speaker's case are second-line for a reason; many are known to be either less effective than first-line treatments or carry more toxic side effects.

Surgery May Be Necessary

If drug therapy turns out to be ineffective, doctors may turn to a treatment that was practiced even before the age of antibiotics -- surgery to remove the infected part of the lung.

This option -- one that Boom calls "stone age" -- may actually help, as cutting out a large proportion of the infected tissue in the lung may give the body a head start in fighting whatever disease remains.

But if it comes to surgery, Ohl said timing and expertise will be crucial.

"There are very few surgeons left in the United States with expertise in knowing when to do surgery for tuberculosis," Ohl said.

"If they wait too long, he may be too sick to get through a difficult surgery. But if they operate too early, he may be exposed to unnecessary surgery."

Health Professionals Cautious

Regardless of the final treatment decision, Speaker will be kept under a tight watch until his infection is rendered noncommunicable.

Even now, doctors say it is unlikely that his disease was passed along to his fellow passengers -- and it would likely be harmless even if it was transmitted.

"Luckily, even if people have been infected with this bacterium, only a small percentage will get sick," Boom said.

"As far as drug-resistant tuberculosis, it does not spread more rapidly or easily than [other forms of] tuberculosis," Schluger said. "Ninety percent of people who are exposed to tuberculosis will never develop the illness."

However, that doesn't mean that health workers at National Jewish are taking any chances.

According to spokesman William Allstetter, Speaker is being kept in a negative pressure room to keep any of the tuberculosis-causing germs from escaping.

The air pumped out from the room passes through a UV-light filter to kill any airborne disease-causing organisms, and all medical personnel who enter the room will wear masks or "moon-suit" style headgear to protect themselves from infection.

Allstetter said in a press conference Thursday morning that Speaker will likely be spending weeks in the isolation room.

"It is really going to depend on the extent of his disease and how well we can treat it," Allstetter said. "He may not leave that room much for several weeks."

Prognosis Remains Uncertain

The slow progress of the disease also means that it will be hard to assess Speaker's chances of survival and recovery for now.

"I think the fact that he is young and otherwise healthy is certainly a point in his favor," Schluger said "I think it is a good sign for him."

Another thing that Speaker and his team of doctors have on their side is time.

"This is not one of those things where the patient is healthy on one day, deathly ill the next, and the next day is no longer with us," Boom said.

Ohl agreed. "This is not an incredible emergency. This is a disease that progresses very slowly, so doctors have some time to make a full assessment."