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1/
Is there a mechanistic rationale for the use of sanatoria in the treatment of tuberculosis?
This is a “cross-over” thread with @AdamRodmanMD's Bedside Rounds Episode 39, "The White Plague". Time for pathophysiology!
bedside-rounds.org/episode-39-the…
Is there a mechanistic rationale for the use of sanatoria in the treatment of tuberculosis?
This is a “cross-over” thread with @AdamRodmanMD's Bedside Rounds Episode 39, "The White Plague". Time for pathophysiology!
bedside-rounds.org/episode-39-the…
2/
As noted on Bedside Rounds, sanatoria were used for decades as a component of Mycobacterium tuberculosis (TB) treatment.
In 1923 Cox performed an analysis of patients treated at sanatoria versus those treated elsewhere. Sanatoria patients did better.
sciencedirect.com/science/articl…
As noted on Bedside Rounds, sanatoria were used for decades as a component of Mycobacterium tuberculosis (TB) treatment.
In 1923 Cox performed an analysis of patients treated at sanatoria versus those treated elsewhere. Sanatoria patients did better.
sciencedirect.com/science/articl…
3/
In Cox's review, mortality was:
14% in sanatorium cases
38% in non-sanatorium cases
Which of the following might explain the benefits of a sanatorium?
In Cox's review, mortality was:
14% in sanatorium cases
38% in non-sanatorium cases
Which of the following might explain the benefits of a sanatorium?
4/
The potential benefits of a sanitorium may be related to increased sunlight. Recall that solar UVB radiation induces the conversion of 7-dehydrocholesterol to previtamin D3 in the skin.
And vitamin D likely has anti-TB effects!
ncbi.nlm.nih.gov/pubmed/17634462
The potential benefits of a sanitorium may be related to increased sunlight. Recall that solar UVB radiation induces the conversion of 7-dehydrocholesterol to previtamin D3 in the skin.
And vitamin D likely has anti-TB effects!
ncbi.nlm.nih.gov/pubmed/17634462
5/
There is quite a bit of data showing that patients with TB have lower vitamin D levels.
While the direction of causality isn't proven, many argue that low vitamin D levels are a risk factor for TB.
ncbi.nlm.nih.gov/pubmed/18173355
There is quite a bit of data showing that patients with TB have lower vitamin D levels.
While the direction of causality isn't proven, many argue that low vitamin D levels are a risk factor for TB.
ncbi.nlm.nih.gov/pubmed/18173355
6/
Put another way, normal/high vitamin D levels may have anti-TB effects.
But what does vitamin D "do"? Early studies suggested that activated (i.e., 1,25-OH) vitamin D promotes macrophage-mediated TB inhibition.
ncbi.nlm.nih.gov/pubmed/3002968
Put another way, normal/high vitamin D levels may have anti-TB effects.
But what does vitamin D "do"? Early studies suggested that activated (i.e., 1,25-OH) vitamin D promotes macrophage-mediated TB inhibition.
ncbi.nlm.nih.gov/pubmed/3002968
7/
In 2006, amazing research added to our understanding. It now seems that:
*TB antigens stimulate toll-like receptor, causing
*up-regulation of vitamin D receptors, causing
*induction of the anti-TB peptide cathelicidin, and
*killing of intracellular TB
ncbi.nlm.nih.gov/pubmed/16497887
In 2006, amazing research added to our understanding. It now seems that:
*TB antigens stimulate toll-like receptor, causing
*up-regulation of vitamin D receptors, causing
*induction of the anti-TB peptide cathelicidin, and
*killing of intracellular TB
ncbi.nlm.nih.gov/pubmed/16497887
8/
Based on the above, which of the following therapies mentioned in Bedside Rounds may have a physiologic basis?
Based on the above, which of the following therapies mentioned in Bedside Rounds may have a physiologic basis?
9/
Cod liver oil is loaded with vitamin D! Reading the case reports of CJB Williams, published 1849, makes one believe that it just might work as a treatment for consumptions (aka phthisis, aka mycobacterium tuberculosis).
bmj.com/content/s2-1/1…
Cod liver oil is loaded with vitamin D! Reading the case reports of CJB Williams, published 1849, makes one believe that it just might work as a treatment for consumptions (aka phthisis, aka mycobacterium tuberculosis).
bmj.com/content/s2-1/1…
10/
Contemporary trials of vitamin D (in the form of tablets, not cod liver oil) have been mixed. Some have shown benefit, others haven't.
A meta-analysis published this year suggests that vitamin D promotes the conversion to TB negative sputum.
ncbi.nlm.nih.gov/pubmed/29954353
Contemporary trials of vitamin D (in the form of tablets, not cod liver oil) have been mixed. Some have shown benefit, others haven't.
A meta-analysis published this year suggests that vitamin D promotes the conversion to TB negative sputum.
ncbi.nlm.nih.gov/pubmed/29954353
11/
One other thing. Recall that TB is on the differential of hypercalcemia, with the mechanism being elevated vitamin D.
It could be that the hypercalcemia suggests appropriate macrophage stimulation in the setting of TB infection. I could not find data supporting this...
One other thing. Recall that TB is on the differential of hypercalcemia, with the mechanism being elevated vitamin D.
It could be that the hypercalcemia suggests appropriate macrophage stimulation in the setting of TB infection. I could not find data supporting this...
12/
To summarize:
*vitamin D has anti-TB effects
*the positive effects of sanatoria may relate to sunlight mediated vitamin D generation
*cod liver oil has tons of vitamin D
*for more cool TB history, listen to Bedside Rounds, episode 39.
bedside-rounds.org/episode-39-the…
To summarize:
*vitamin D has anti-TB effects
*the positive effects of sanatoria may relate to sunlight mediated vitamin D generation
*cod liver oil has tons of vitamin D
*for more cool TB history, listen to Bedside Rounds, episode 39.
bedside-rounds.org/episode-39-the…
