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Volume 8, Number 11—November 2002
THEME ISSUE
Tuberculosis Genotyping

Tuberculosis Genotyping Network, United States

Estimated Costs of False Laboratory Diagnoses of Tuberculosis in Three Patients

Jill M. Northrup*Comments to Author , Ann C. Miller*, Edward Nardell*†, Sharon Sharnprapai*, Sue Etkind*, Jeffrey Driscoll‡, Michael McGarry‡, Harry W. Taber‡, Paul Elvin*, Noreen L. Qualls§, and Christopher R. Braden§
Author affiliations: *Massachusetts Department of Public Health, Boston, Massachusetts, USA; †Harvard Medical School, Boston, Massachusetts, USA; ‡New York State Department of Health, Wadsworth Center, Albany, New York, USA; §Centers for Disease Control and Prevention, Atlanta, Georgia, USA;

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Table 2

Characteristics of patients who received misdiagnoses of active tuberculosis disease resulting from laboratory cross-contamination of Mycobacterium tuberculosis specimensa

Characteristics Patient 1 Patient 2 Patient 3
Demographic information
Age at diagnosis (yrs) 59 29 38
Sex Female Male Male
Clinical information
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
TST result Negative Negative Negative
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
Contact investigations
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.

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