A killer returns.

Tuberculosis, a disease we thought was conquered several decades ago along with smallpox and diphtheria, is on the rise.

Nearly three months had passed since she first noticed the cough. It had gradually taken over her life, wracking her small frame by day and keeping her awake at night. Now Lena stood looking down at the bathroom scale, realizing that yet another pound had disappeared. Her appetite had simply evaporated. Her husband was concerned, close friends had begun inquiring about her health. She couldn't blame them; her clothes hung on her like garments on a garden scarecrow. They urged her to see a physician, but she refused. She was afraid.

Five years ago she had buried her mother, a victim of lung cancer. Three years ago she had done the same for a favorite niece. She just knew the same enemy that had snuffed out their lives was now stalking her. She was so certain of it, so terrified, that she wouldn't telephone her family physician or darken the doorway of his office.

Working full-time as a waiter had become more than Lena could handle. It would be difficult for the family to get along on a smaller paycheck, but she was simply dead tired by the end of eight hours; she actually felt guilty for not working up to par.

At her request, the owner agreed to reduce her shift to six hours.

Overwhelming weakness. Several weeks went by. Her condition worsened. Thinking a change of scenery would help, she decided to spend a few days visiting close friends who lived in a neighboring county. While there, she noticed that when she coughed up mucus it was tinged with blood.

Since she now felt over-whelming weakness, she drove herself to a nearby emergency room. a doctor examined her and, suspecting pneumonia, insisted on admitting her to the hospital. Lena went through the routine she had seen implemented for both her mother and her niece--chest X-rays, blood tests, a urinalysis, and in her case, an HIV test, just to rule out AIDS. According to the physician assigned to her case, the X-ray showed what appeared to be massive destruction of lung tissue.

Two days later, when the intravenous antibiotics had neither stayed her fever nor brought back a sparkle to her eyes, an infectious disease specialist (IDS) was summoned. He stood at the nursing station and flipped through the medical record with practiced hand. Lena Jarvis;* Caucasian female; age 48 (48? She looked 60!); persistent productive cough; blood-tinged mucus; night sweats; fever; familial history of lung cancer; negative HIV test. He noted with satisfaction that the nursing staff had begun masking soon after admission. Whenever Lena left her room for any reason (which was infrequent), they had asked that she wear a mask as well. Wise precaution, he mused, and immediately ordered a number of additional tests, including skin tests for coccidiomycosis, San Joaquin valley fever, and tuberculosis. One could not be too cautious when a patient was this sick.

Tuberculosis suspected. Another 48 hours sped by. Lena's condition continued to deteriorate. Two of the skin tests were read as negative; one was positive. Highly positive. The IDS ordered a series of sputum tests and then waited for the results. When the telephone rang in his office, it was the laboratory microbiologist, who had called to report that the microscopic examination of Lena's sputum suggested tuberculosis. They were sending the specimen out to another lab for confirmation. The IDS telephoned the hospital with orders for the latest TB medications. Aggressive treatment based on those lab reports should surely bring a significant improvement.

Because of the severity of Lena's illness, the IDS presented a Grand Rounds to the medical staff. Briefly he outlined the facts of her case and went on to make several points:

* Cases of pulmonary tuberculosis were on the rise nationwide since 1989 (after a 30-year decline from 84,000 cases in 1953 to 22,000 in 1984).

* Recently some strains of TB were showing resistance to many of the antibiotics commonly used to treat the infection--an ominous sign.

* More people were presently at risk for TB: individuals with underlying HIV infection immigrants from countries with higher rates of TB the elderly the homeless those living in crowded living conditions and/or poverty

* There seemed to be a national complacency toward a conquered disease that was reflected in a withdrawal of funding for TB control and a decline in research related to diagnosis and treatment.

The director of infection control notified the county health department to follow up with Lena's family, friends, and contacts. She had not seen a case of primary pulmonary TB like this since her public health nursing days on a Navajo reservation more than 20 years earlier. She arranged educational presentations for hospital personnel and interviewed employees in order to identify those who had been exposed to the TB organisms without adequate protection. Fortunately, most of the nursing personnel had worn masks when caring for Lena (or had masked her).

The employee occupational health nurse was busy giving skin tests to exposed employees. She was also writing a proposal to hospital administration to reinstate annual TB skin testing for all employees. As in many other healthcare facilities, the TB testing protocol had been waived some years before because of the low number of TB cases that crossed the threshold.

The killer returns. The nursing personnel assigned to Lena's care grew increasingly concerned. They were accustomed to seeing TB once in a while, usually in recent immigrants or the elderly. Patients who took their medication got well and went home. No one died of TB these days--not in the nineties. But Lena's condition was not improving. Even the infectious disease specialist began to anticipate a gloomy outcome as Lena lay in bed lethargic, her whole system toxic from the infection. Medical science could offer her nothing more. Would the sophisticated medications turn her infection around?

Several days later, although still under the care of a state-of-the-art medical team, Lena's disease-ravaged lungs gave up the struggle. Tuberculosis, the killer, had returned. It had attacked an average, otherwise-healthy woman who was not even in a high-risk category--and won. The forgotten disease--one that everyone thought had been conquered several decades ago along with smallpox and diphtheria--was back.

The hospital staff talked about tuberculosis at lunch breaks. Lena's untimely death had provided a tragic although practical object lesson to all. If only she hadn't assumed that her cough was lung cancer, she could have saved herself months of suffering; if only she had sought medical treatment earlier, she would have avoided exposing hundreds of people to TB; if only she had not allowed her fears to deprive her family of a wife and mother; if only she had not practiced self-diagnosis, she might be alive and on the road to recovery; if only they could have been involved in her life earlier. At least Lena's story could serve to alert others.