A 45-year-old man comes to the emergency department due to progressive back pain for the past several weeks. He has also had poor appetite and lost 2.3 kg (5 lb) over this period. The patient notes productive cough but attributes this to chronic cigarette smoking. He has had no back trauma, lower extremity weakness or numbness, or loss of bladder or bowel control. The patient has no prior medical problems and takes no medications. He has smoked 2 packs of cigarettes daily for 25 years and is trying to quit. The patient came to the United States 2 months ago from Eastern Europe to visit his son. Temperature is 37.4 C (99.4 F), blood pressure is 140/80 mm Hg, and pulse is 84/min. Lung auscultation reveals occasional left-sided rhonchi and crackles. Back examination shows midline tenderness in the lower thoracic region. Neurologic examination is normal. Chest x-ray reveals a cavitary lesion in the left upper lobe, and spine imaging indicates vertebral osteomyelitis and discitis. The patient is immediately isolated and sputum samples are obtained. Sputum for acid-fast bacilli is positive, and antituberculosis treatment is initiated. His close contacts are advised to obtain medical evaluation. Health care personnel who administered care to the patient prior to infection control measures have negative tuberculin skin testing. Which of the following is the next most appropriate step for the health care workers with potential exposure?

Question

A 45-year-old man comes to the emergency department due to progressive back pain for the past several weeks.  He has also had poor appetite and lost 2.3 kg (5 lb) over this period.  The patient notes productive cough but attributes this to chronic cigarette smoking.  He has had no back trauma, lower extremity weakness or numbness, or loss of bladder or bowel control.  The patient has no prior medical problems and takes no medications.  He has smoked 2 packs of cigarettes daily for 25 years and is trying to quit.  The patient came to the United States 2 months ago from Eastern Europe to visit his son.  Temperature is 37.4 C (99.4 F), blood pressure is 140/80 mm Hg, and pulse is 84/min.  Lung auscultation reveals occasional left-sided rhonchi and crackles.  Back examination shows midline tenderness in the lower thoracic region.  Neurologic examination is normal.  Chest x-ray reveals a cavitary lesion in the left upper lobe, and spine imaging indicates vertebral osteomyelitis and discitis.  The patient is immediately isolated and sputum samples are obtained.  Sputum for acid-fast bacilli is positive, and antituberculosis treatment is initiated.  His close contacts are advised to obtain medical evaluation.  Health care personnel who administered care to the patient prior to infection control measures have negative tuberculin skin testing.  Which of the following is the next most appropriate step for the health care workers with potential exposure?

Quizplus · Accepted Answer

Explanation: This patient from Eastern Europe has an upper lobe cavitary pulmonary infiltrate, vertebral osteomyelitis, and positive acid-fast bacilli on sputum smear suggesting active Mycobacterium tuberculosis of the lungs and spine (Pott disease). Patients with active pulmonary tuberculosis (TB) may transmit the bacterium to close contacts via aerosolized droplets for up to 3 months prior to the onset of symptoms. Health care personnel are typically at risk during the early diagnostic process, prior to the initiation of appropriate infection control measures (airborne isolation, use of N95 mask). To evaluate potential exposure, screening with tuberculin skin testing or interferon-gamma release assay is required. If initial screening is negative, repeat testing at 8-10 weeks can confirm whether transmission occurred. (Choice A) Screening tests for TB may be negative for up to 8 weeks following exposure; repeat testing is required to evaluate for transmission so that appropriate treatment may be administered. (Choices B and D) If screening for TB is positive, chest x-ray and sputum testing for acid-fast bacilli are required to evaluate for active TB. If both of these additional tests are negative (and no symptoms of TB are present), patients are usually treated for latent TB with isoniazid and pyridoxine. (Choice E) Patients with symptoms of TB (eg, fever, hemoptysis) are categorized as having active TB. Screening helps identify cases of latent TB so that these can be treated prior to converting to active TB. Educational objective: Patients with active pulmonary tuberculosis are at risk of transmitting Mycobacterium tuberculosis to close contacts for up to 3 months prior to the onset of symptoms. Health care personnel are also at risk until appropriate infection control measures (airborne isolation, N95 mask) are undertaken. Those with potential exposure should receive screening with tuberculin skin testing or interferon-gamma release assay. If negative, screening should be repeated at 8-10 weeks.

A 45-Year-Old Man Comes to the Emergency Department Due to Progressive