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*
, 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§
, 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§
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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