Thirty years working in the UK and I had never diagnosed a case of TB. In Masindi I seem to see several new cases a week. TB is often a co-infection with HIV so most clinics we see patients who may have TB. Some of these patients are very sick and many will die in spite of treatment. Diagnosis is not easy, our lab is under staffed and has only one poor microscope. Over the past few years several microscopes have been stolen. We are promised a new one once we have somewhere secure to keep it.The best way to diagnose TB is by microscopy of sputum samples.The logistics of getting 3 samples on seperate days to the lab is far from simple when patients live miles away from the hospital and have no transport.Some of the lab staff are not interested and do not accept samples or leave them too long to process them. The other way of diagnosing is by xray.Getting an xray is not always easy. This week the hospital has no films.The xray machine needs electricity so you can not take an xray if there is a power cut which happens for some part of most days.Once you have an xray it has to be interprated and here it is me who has to do that!.It is along time since i looked at xrays, you do not see them in general practice. Luckily another VSO volunteer Grania is working in Kampala and is a chest specialist. I regularly send xrays down to her either by taxi or even on the bus. Grania reports them and I can have a report back in a couple of days. A faster service than the NHS could manage in Hull. Grania is fascinated by our xrays because the changes are often so extreme. Patients here present late so the xrays can look unbelievable. Unfortunately Grania returns to London in September which will be a real blow.I will miss her support.
Last week I saw a little boy who Pam had seen on out reach. He had a swelling and deformity of his spine and was generally miserable.At the clinic I found out his father had TB. I arranged an xray which he was delayed because of no electricity but the next day he had one which confirmed my suspicion of TB spine.At 18 months this is a tragedy but he should do well with treatment.I referred him for treatment last week but he still has not started because the childrens doses are not in Masindi. I am still trying to get hold of the right treatment but if there is any more delay he will have to start on a fraction of adult tablets.
This week I also received confirmation that one of my patients has multi drug resistant TB. Raymond has been a volunteer at the hospital for many years and has had 5 courses of treatment for TB. I shared an office with him for the first few months of my stay here.When I realised he was still coughing up TB bacilli we agreed he would stop work at the clinic.I arranged for him to be seen in Kampala and after 3 months his TB culture has confirmed his TB is resistant to 4 of the standard drugs. It is remarkable that Raymond is still alive and active.Unfortunately there is no treatment available for him in Uganda. The drugs for MDRTB are very expensive and not available in Uganda. Raymond is one of many patients who waits for funding for exceptional treatment
In spite of the difficulties TB is a satisfying disease to treat. If you get the diagnosis right patients respond well and rapidly start to feel better, gain weight and get back to working.One of the challenges is that many patients do not finish the 8 months course of treatment. Follow up is poor and patients are lost to the service. This creates a real risk of developing resistant TB.
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