Volume 8, Number 11—November 2002
Tuberculosis Genotyping Network, United States
Estimated Costs of False Laboratory Diagnoses of Tuberculosis in Three Patients
|Characteristics||Patient 1||Patient 2||Patient 3|
|Age at diagnosis (yrs)||59||29||38|
|Site of disease||Lymphatic||Pulmonary||Soft tissue, right index finger|
|Symptoms when examined||Chronic cough, weight loss, increasing fatigue, night sweats (Sept 1998)||Abdominal discomfort, diarrhea, flank pain, high fever, cough with blood, delirium tremens (Nov 1998)||Infection of right index finger,b great pain, lymphangitic streaks up arm (Aug 1998)|
|Radiology, initial||CAT scan: lymphadenopathy, densities in upper lobes suggestive of infiltration or scarring||Chest x-ray: right lower lobe infiltrate, improved with intravenous ceftriaxone||X-ray right hand: swelling over right index DIP and PIP joints; chest x-ray: normal|
|Pathology||Lymph node biopsy positive for lymphoma, chemotherapy started||Not applicable||Not done/missing|
|Underlying conditions and TB risk factors||History of Hodgkin lymphoma and treatment for active TB disease in 1995,c non–U.S.-born||History of chronic alcohol abuse and cocaine use||HIV positive, history of IVDU and incarceration|
|TB health care|
|TB health-care provider||Private physician||Public health department TB clinic||Public health department TB clinic, correctional facility clinic|
|Type of TB therapy||Self-administered||Daily DOT by public health nurse||Daily DOT by correctional facility staff|
|Duration of TB therapy||<1 month (started Dec 1998)||<2 months (started Dec 1998)||11 months (treated for 2 weeks in Oct 1998, restarted December 1998)|
|Hospitalization(s) following TB diagnosis||5 days in private hospital (Jan 1999) with increasing respiratory distress, treated for community acquired pneumonia, died of presumed progression of non–Hodgkin lymphoma||11 days in private hospital with acute gastritis secondary to alcohol abuse (Jan 1999), TB therapy discontinued secondary to increased LFTs; 15 days at public health hospital for TB management; TB ruled out||8 days at public health hospital to start anti-TB therapy and rule out pulmonary and bone involvement (Oct 1998); 5 days in correctional facility infirmary|
|By public health department||Not done||One household contact identified, TST-negative||Not done|
|By hospital infection control||Not done||Not done||Not done|
|Information on cross-contaminated specimen|
|Specimen type||Right inguinal lymph node tissue||Sputum||Swab of finger cellulitis|
|AFB smear result||Negative||Negative||Negative|
|AFB culture result||1 colony at 60 days (reported Dec 1998), sensitive to INH, RIF, EMB, Strep (PZA not tested)||1 colony at 40 days (reported Dec 1998), slightly resistant to INH||“Rare” colonies at 42 days (reported Sept 1998), INH resistant|
|NTGSN IS6110 RFLP analysis||10-band pattern (reported April 1999), RFLP match to an isolate from a known TB patient||9-band pattern (reported April 1999), RFLP match to an isolate from a known TB patient||16-band pattern (reported Oct 1999), RFLP match to laboratory control strain H37Ra|
|Case appraisal resultsd|
|Case diagnosis||Lymphoma, nosocomial bacterial pneumonia||Community-acquired pneumonia||Streptococcus cellulitis|
|Did laboratory cross-contamination occur?||Likely||Likely||Likely|
aTST, tuberculin skin test; TB, tuberculosis; CAT, computerized axial tomograpy; AFB, acid-fast bacilli; NTGSN, National Tuberculosis Genotyping and Surveillance Network; RFLP, restriction fragment length polymorphism; INH, isoniazid; RIF, rifampin; EMB, ethambutol; Strep, streptomycin; PZA, pyrazinamide; DOT, directly observed therapy; LFTs, liver function tests; DIP, distal interphalangeal; PIP, proximal interphalangeal; and IVDU, intravenous drug use.
bInfection of right index finger ultimately resulting in amputation; specimen grew Streptococcus Group A.
cPatient treated for active TB disease in 1995, although there was not enough evidence to verify the case for national surveillance.
dCase appraisals performed by a panel of three TB investigators representing other NTGSN sentinel sites.