Clinical problem

A 22-year-old woman native of South Carolina presented to an emergency department (ED) with right-sided chest pain. She was afebrile and not coughing. As a toddler, she was exposed to her aunt who had cavitary tuberculosis. The daughter of that aunt contracted tuberculosis. Both the aunt and child were treated with anti-tuberculosis therapy. As a child with contact, the patient was given anti-tuberculosis prophylaxis for six to eight months, as she remembered. She said she was adherent to the prophylaxis. She was unable to produce any expectorated sputum.

On exam, her vital signs were normal and there were minimal findings. The right side of the chest was tender to palpation. The chest film and chest CT showed minimal pleural reaction of the right lung, but a large left upper lobe cavitation. Initial laboratory findings were unremarkable.

The emergency physicians had several questions: Are there provisions for handling the patient before hospital admission? Have emergency personnel had a significant exposure? How can personnel be tested for infection? Should the patient be treated immediately?

COMMENTARY

Along with HIV, tuberculosis (TB) remains the leading cause of death worldwide. Even though these deaths occur in 22 so-called high-burden countries, TB remains a problem in the United States. Multidrug-resistant TB now accounts for 3.3% of new cases but 20% of repeat cases. Prophylaxis, when used, remains an effective cornerstone of prevention. Healthcare workers (HCWs) in high-burden countries in particular remain at high risk of TB. Every 21 seconds, a person dies of TB, including some healthcare professionals.

The ED physicians noted above have very important and meaningful questions. The May 15, 2016, supplement to Clinical Infectious Diseases is devoted to a single topic: Healthcare Workers and Tuberculosis Prevention. There are seven provocative original articles, primarily from South Africa, but with information and data applicable worldwide.

Central to these articles is the theme of protecting our front-line HCWs. Very few of the high-burden countries have TB infection control reporting. We are very lucky in the United States to have dealt with prevention of TB in HCWs, but we can always do more, as evidenced by the questions that arose in the case described. There are four defenses put forward by Verkuijl and Middelkoop in the first article. Four lines of defense from exposure to tuberculosis in healthcare workers are managerial, administrative, environmental, and personal. At all times the fears of HCWs must be taken into account, in some cases to insure that information on drug resistance comes quickly to infection control in the event that infection would occur in an HCW.

Because of rapid air travel and fluid national borders, citizens of high-burden countries quickly can become residents of developed countries, presenting problems of TB contagion to first-world healthcare systems. For that reason, the strategies throughout this symposium based on high-burden countries resonate with implications for more developed nations.

The article by Tudor et al finds that the major occupational risk for TB for HCWs in KwaZulu-Natal is HIV, a finding that can perhaps be extended to our HCWs who may be immunosuppressed. In the last article by von Delft et al, HCWs and students in Cape Town have the impression, right within their resource-poor setting, that they are not susceptible to TB, even though there is a high degree of occupational TB exposure. Clearly there is a need for funding at a much higher level to protect HCWs from acquisition of TB. The articles in this symposium highlight that immense need.

As for our patient described in the case, it turned out that the initial acid fast smears were positive, suggesting TB was actually the cause of the cavitary disease. The patient was placed into a negative-pressure room present in the ED. The patient was not coughing to any extent, so the exposure to ED personnel may be reduced, but there was some exposure concern before the patient was placed into the negative-pressure room. Standard tuberculin testing should be performed after HCWs have had adequate time to make a delayed type skin response. Some hospitals would make testing for gamma-interferon release available (Quantiferon testing), but the ideal time for Quantiferon testing after an exposure has not yet been established. The patient was placed on an anti-tuberculosis regimen consisting of four agents the second day of admission. More rapid means of determining if M. tuberculosis is the pathogen are in development and would certainly add to the quality of care in the present case.