President: Dr David Rowen FRCP
A meeting of the Southampton Medical Society was held on the 7th February 2024 to hear the Foott Memorial Lecture. The President was in the chair. A short silence was observed in memory of Mr Iain Boyd FRCOG who had died recently.
The minutes of the last meeting were approved.
The President introduced Dr Ben Marshall FRCP PhD, Consultant and Associate Professor of Respiratory Medicine at SGH who was delivering the Foott Memorial Lecture for 2024 with the title ‘Tuberculosis - Past, Present and Future.’ He thanked the Society for the privilege of giving this lecture. He started with some personal history which led to his qualifying at St Mary’s. His PhD was concerned with genetically engineering the BCG Vaccine to express mammalian cytokine genes.
He said that TB has been demonstrated in Neolithic remains. This was a period when man became domesticated and cattle lived in very close proximity. TB-Bovine and TB-Mankind are very close genetically. X-rays of ancient Egyptian mummies and Pre-Colombian mummies showed evidence of TB.
He said he recently visited the Royal College of Physicians Garden of Medicinal Plants in London. Artemisia, or wormwood, was one of the plants which was used to inhibit tuberculosis. Papaya leaves which are burned, and the smoke inhaled, contain alkaloids which inhibit TB and were used in Africa. On a recent visit to Rome he visited the garden of Keats’ House [by the Spanish Steps]. It was where Keats died of TB having contracted it as a medical student.
Dr Marshall said that in 1848 a trial was conducted at the Brompton Hospital which showed that by giving cod liver oil to TB patients 63% improved and had less chance of death. That was in an age when 1 in 3 people contracted TB and 50% died young.
Robert Koch proved TB was a bacterial infection and eventually won the Nobel Prize for his work on TB. Camille Guerain passed the bacillus through potatoes many times to attenuate it and the result was the BCG.
Dr Marshall then discussed the history of various treatments. He said that most patients get through the massive drug taking required nowadays which lasts18 - 24 months.
TB is a great mimic he said. The traditional symptoms of cough, haemoptysis, weight loss, fevers and night sweats are not necessarily how it presents as there are Latent cases as well as Active ones. Latent patients just live with it. Fifty per cent of patients nowadays will have TB at sites other than in the lungs. The point of entry is via the lung but macrophages carry the bacillus around the body to other sites. Our speaker himself developed
Tuberculous Choroidal Retinitis which he caught in London. He took 4 drugs for 12 months.
The incidence of TB was declining in the years before the first world war which was before treatment was readily available. In 1964 there were 140 cases recorded. However in the years after 2000 the numbers took off. He now sees 20 to 30 cases a year. He discussed the concept of Latency. T cells form granulomas around the bacteria in effect locking them away. However, HIV kills T cells and so TB goes “wild” in this group of patients. There is also a high incidence in those patients with type 2 diabetes, inflammatory bowel disease, those taking anti-TNF drugs, which disrupt the granulomas, [TNF controls the formation of granulomas] and cigarette smoking.
Southampton now has 5 TB consultants along with specialist TB nurses and microbiologists. For any outbreaks, such as in hospital or schools, CDCs come in to screen contacts for potential cases and carriers.
There is now a global threat from multi drug resistant TB [MDRTB] where it is necessary to resort to second line treatments which are more toxic and have to be taken for longer. In India this applies to 4% of the population and Russia and the Baltic States [Lithuania especially] and Africa have a high incidence. There are more people dying of it due to the increase in world population. Southampton has a number of MDRTB cases, and also XDRTB cases which are untreatable.
Dr Marshall said the future will bring new vaccines and treatments. Unfortunately most TB is in developing countries which have no infrastructure to deliver these benefits.
Questions afterwards highlighted:
Twin studies have shown there is a genetic link to innate resistance.
Many Afghan patients arriving in the UK may have TB.
Fifty percent of far eastern nurses test positive for TB.
BCG can be a very effective treatment for MDRTB cases in about 50% of patients.
If medical students are travelling abroad for more than 6 weeks they should have a baseline test before they go and repeat it on return.
Bill Gates funds TB research and treatment generously.
The President then thanked Ben for such a stimulating and enthralling lecture.
There being no other business the meeting was closed.