INDIA: WHEN TB IS ALWAYS IN THE DDX

By Aislinn McMillan

‘Endometrium.’ ‘Cystic lesions from cerebellum.’ ‘Gluteal abscess.’ ‘Fluid from knee’. ‘Placenta.’ ‘Collection around heel.’ As I sift through diagnostic registers, these are just a few of the types of samples types I see.

Like many of my classmates, I relied heavily on a study resource called SketchyMedical to learn microbiology. This resource is a program of videos that teaches microbiology pathogens using animated cartoons full of memory tricks. When I thought of tuberculosis, I would think of the western theme cartoon titled “Shootout at the TB Corral.” Bullet holes in the middle of a cactus represented primary TB primarily affecting the middle lobes of the lung; millet represented miliary TB; cracked pots represented Pott’s disease. Little did I realize the extent of variability of site of infection or how diverse its course could be until I began my summer in India.

I start my mornings walking from the flat I am renting to the bus stop and am immediately confronted by untraceable smells and the honks of rickshaws and motorbikes zooming through the streets. Often, I am also wielding an umbrella since it’s monsoon season and all. One thing I’ve learned this summer is how to maneuver an umbrella every direction through crowded streets. At my bus stop, the buses always have the bus number written in the Hindi alphabet on the front. Sometimes they have it written in the English alphabet on the back of the bus. Sometimes they don’t, in which case I hope the person next to me knows English and answers fast enough for me to hop on as the buses barely stop. I sit in the front part of the bus that is reserved for women (train compartments, airport security, etc. all have different sections for women here). When I get off the bus in a more bustling area of the city, I have to watch where I walk. I’ve learned to always look down as I walk as you never know when there is going to be cow poop in the street. Commuting to work is just the beginning of the excitement of the day living in Mumbai.

My flat building

For the past seven weeks, I have been working on a retrospective data collation and analysis research project at Hinduja Hospital & Clinical Laboratories in Mumbai. The Hinduja Laboratory is a reference laboratory attached to a very large private hospital with a sizeable and diverse tuberculosis population. Although it is a private hospital, it also runs as a philanthropy and serves the city of Mumbai as well as the greater area. Despite India’s huge population, wealth inequalities, and the large proportion struggling in the face of poverty, over half of India’s TB patients seek care in the private sector. This reflects the lack of capacity and infrastructure that patients find in the public sector.

Hinduja Hospital

I am amazed at the volume and diversity of samples the microbiology lab receives each day. Not only do they receive samples from patients at Hinduja Hospital, but also all sorts of other health facilities around Mumbai, including MSF. The lab receives samples with all sorts of suspected infections—TB, H1N1, C. Diff, CMV—and has different work flows dependent on the sample type and what the doctor orders. The phones in the lab are constantly ringing as people call in asking about results.

In short, the objective of my research is to evaluate the performance of a rapid molecular diagnostic platform, called line probe assays (LPAs), for use in diagnosing tuberculosis and determining drug resistance in extrapulmonary samples. These assays involve three steps: DNA extraction from clinical specimens or cultured material, PCR amplification of predefined gene regions, and reverse hybridization of the PCR products with standard, immobilized probes for gene mutations associated with resistance. This diagnostic platform has been well profiled for pulmonary samples and is endorsed by the WHO for them. However, research into LPAs performance on extrapulmonary samples lags behind.

The number of new cases of TB reported to WHO has been increasing since 2013, largely due to increased reporting of detected cases by the private sector in India, which accounts for about a quarter of the TB case burden. It is estimated that 15-20% of all TB is extrapulmonary. Since clinical presentation of extrapulmonary TB is so diverse, it is often misdiagnosed, leading to improper and delayed treatment. Moreover, the emergence of severe forms of drug resistance has complicated the treatment of all types of TB.

Me and my PI, Dr. Camilla Rodrigues

To supplement my research, I have been shadowing a pulmonologist with a special interest in extensively drug-resistant tuberculosis and rounding with the infectious disease team in the hospital. I see how differently the differential diagnosis unfolds here. Infertility? Think TB of the fallopian tubes. Pleural effusion? Again, think TB. Not sure what could be causing the clinical manifestations? Probably TB.

Me and Dr. Ayesha’s infectious disease team

Through my research and time in the hospital, I have seen many of the intricacies, differences, and some of the challenges that come with being a healthcare provider and being a researcher here. Serving the greater population of Mumbai, people’s financial constraints play a major role since most patients are paying out of pocket. I see doctors working to get patients on studies to help decrease the patient’s financial burden. Here, patients carry their own medical records (they carry huge bags with all notes, X-rays, CT-scans, etc.), so physicians must sift through all the records and decipher other doctor’s handwritten notes from other health institutions. Moreover, I’ve seen cases where patients have lost their records, and thus the doctor must treat the patient blind to history of prior infections, drug regimens, etc.

I’ve also gotten to experience some of the joys and excitement of working here. To name a few– the diagnostics technologies are incredible, and the lab handles such a large volume of samples. Doctors treat such a diversity of infections that always keep you on your toes. I’ve learned that a huge part of infectious disease is also learning when not to treat. The support from and focus on family is very evident and heartwarming, as rarely does just the patient come into the room. Chai breaks are frequent between monsoon showers. Today was my last day of work, and I am so grateful for this immersive experience and insight into TB diagnostics and treatment, and to all the people who have taught me and inspired me during my time at Hinduja.

I’m headed to the Himalayas now, but hope to return to Mumbai in the future! Another blog post coming soon.

Chai by the seaside with my coworkers Saurabh and Nasheed

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s