A 52-year-old nursing home worker comes to the office with a 4-week history of nonproductive cough and night-time sweating. She has unintentionally lost 2.2 kg (5 lb) over the last month. Her medical history is significant for untreated hepatitis C and left-sided mastectomy for breast cancer 5 years ago. She tested negative for HIV 6 months ago. The patient takes no medications but smokes 1 pack of cigarettes daily and drinks 2 beers every weekend. She emigrated from Vietnam 2 years ago. Chest x-ray shows a right upper-lobe cavity with a surrounding infiltrate. Which of the following is the most important epidemiologic clue to the etiology of this patient's disease?

Question

A 52-year-old nursing home worker comes to the office with a 4-week history of nonproductive cough and night-time sweating.  She has unintentionally lost 2.2 kg (5 lb) over the last month.  Her medical history is significant for untreated hepatitis C and left-sided mastectomy for breast cancer 5 years ago.  She tested negative for HIV 6 months ago.  The patient takes no medications but smokes 1 pack of cigarettes daily and drinks 2 beers every weekend.  She emigrated from Vietnam 2 years ago.  Chest x-ray shows a right upper-lobe cavity with a surrounding infiltrate.  Which of the following is the most important epidemiologic clue to the etiology of this patient's disease?

Quizplus · Accepted Answer

This patient most likely has reactivated tuberculosis (TB). Reactivation of latent TB typically causes an apical cavitary lesion seen on the chest x-ray. Generally, patients report chronic low-grade fever as well as night sweats and weight loss (as seen in this patient); a cough productive of blood-tinged sputum is classic, but its absence does not exclude TB. Most TB cases in the United States (US) occur in foreign-born individuals who have recently emigrated from endemic areas (eg, Mexico, the Philippines, China, Vietnam, India, Dominican Republic, Haiti). The risk is highest for those who have lived in the US ≤5 years, with an extremely high case rate in the first year after entry into the US. Even after 5 years, the rates are still up to 10 times higher than US-born individuals. Most of these cases represent reactivation of latent TB rather than a new infection acquired in the local community. As a result, screening and treatment of latent TB is recommended for immigrants and refugees coming to the US. (Choice B) Hepatitis C is a risk factor for cirrhosis, hepatocellular cancer, cryoglobulinemia, and glomerulonephritis. Injection drug use, homelessness, or incarceration associated with hepatitis C may confer higher risk of TB infection. However, hepatitis C alone is not a risk factor for TB. (Choice C) Health care (including nursing home) and prison workers come into contact with people who have TB more frequently than the general public, but this patient's recent emigration from an endemic area is a more significant risk factor. (Choice D) Risk of TB infection is increased in patients who are immunocompromised (eg, diagnosed with HIV, on immunosuppression), have a history of hematologic malignancy or head and neck cancer. There is no significant association with breast cancer. (Choice E) Although smoking increases the risk for TB infection and active disease, emigration from an endemic area is a more important risk factor. Smoking is a risk factor for occlusive arterial disease and various forms of cancer (squamous and small cell lung cancer, pancreatic cancer, cancers of the upper aerodigestive tract). Educational objective: Most cases of active tuberculosis in the United States occur in foreign-born individuals who have recently emigrated from endemic areas (especially Mexico, the Philippines, China, Vietnam, India, Dominican Republic, and Haiti), with the highest rates for those arriving in the last 5 years. References: Tuberculosis among Foreign-born Persons in the United States: Achieving Tuberculosis Elimination (http://www.ncbi.nlm.nih.gov/pubmed/17038659)

A 52-Year-Old Nursing Home Worker Comes to the Office with a 4-Week